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PRIMARY 
MALIGNANT    GROWTHS 

OF    THE 

LUNGS    AND    BRONCHI 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/primarymalignantOOadle 


PRIMAEY 
MALIGNANT   GROWTHS 

OF  THE 

LUNGS  AND  BRONCHI 

A    PATHOLOGICAL 
AND  CLINICAL  STUDY 


BY 

I.  ABLER,  A.M.,  M.D., 

Professor  Emeritus  at  the  New  York  Polyclinic,  Consulting 
Physician  to  the  German,  Beth-Israel,  Har  Moriah, 
and  Peoples  Hospitals,  and  Montefiore 
Home  and  Hospital 


'Oportet  omnia  signa  contemplari' 


LONGMANS,    GREEN,    AND    CO. 

FOURTH  AVENUE   &  30TH   STREET,   NEW   YORK 

LONDON,   BOMBAY,   AND   CALCUTTA 

1912 


COPYRIGHT,  1912,  BY 
I.  ABLER,  A.M.,  M.D. 


All  Bights  Reserved 


THE'PLIMPTON'PRESS 

[ W  •  D  •  o] 
NORWOOD.  MASS'U'S -A 


TO 

MY   OLD-TIME   TEACHER  AND   FRIEND 

HIS   EXCELLENCY 

GEH.   RAT.   PROF.   DR.   JULIUS  ARNOLD 

IN    HEIDELBERG 
IN  GRATITUDE  AND   AFFECTION 


PEEFACE 

T  HAD  intended  that  this  little  monograph  on  lung 
■^  tumors  should  be  handed  to  Professor  Arnold  on  the 
occasion  of  the  festival  held  August  19, 1905,  to  celebrate  the 
seventieth  birthday  of  the  master.  The  plan  as  originally 
conceived  could  not  be  carried  out,  but  it  is  hoped  that  the 
delay  in  bringing  out  the  work  may  not  have  been  alto- 
gether valueless  in  that  it  made  possible  a  considerable 
increase  in  the  volume  of  the  material.  Great  thanks  are 
due  to  my  friends  and  assistants.  Dr.  O.  Hensel  and  Dr. 
O.  F.  Krehbiel,  for  their  indispensable  aid  in  collecting  and 
sifting  the  material.  I  am  greatly  indebted,  as  well,  to 
Miss  Laura  E.  Smith,  of  the  Library  of  the  New  York  Acad- 
emy of  Medicine.  I  wish  also  to  express  my  sincere 
thanks  to  Dr.  H.  S.  Tienken  for  her  untiring  interest,  un- 
selfish devotion,  and  technical  skill  in  the  proper  recording 
and  tabulating  of  the  material,  and  to  Dr.  A.  L.  Garbat 
and  to  Miss  F.  H.  Fiske  for  the  strenuous  work  of  seeing 
it  through  the  press.  Finally,  I  would  acknowledge  my 
debt  to  Dr.  F.  S.  Mandlebaum  of  New  York  and  to  Professor 
S.  B.  Wolbach  of  Boston  for  the  very  beautiful  photographs 
used  here  as  illustrations. 

The  author  dares  to  hope  for  kindly  criticism  and  some 
renewed  interest  in  the  subject. 

I.  ADLER 

New  York,  Christmas,  1911 


vii 


CONTENTS 

CHAPTER  PAGE 

I.   Introductory 3 

Mostly  statistical, 

II.   Introductory  {Continued) 13 

Remarks  on  Plan  oj  Monograph. 

III.  A  Few  Historical  Notes 16 

The  Precancerous  Influences. 

IV.  Precancerous  Influences  (Continued)    ....       26 

Etiology  of  Malignant  Tumors  —  Relation  of  Tuberculosis  to 
Lung  Tumors. 

V.   Pathology 39 

Gross  Appearance  of  Lung  Tumors  — A  Minute  Study  of 
Sarcoma  and  Carcinoma. 

VI.   Pathology  (Continued) 55 

Histogenesis  of  Carcinoma  — Endothelioma. 

VII.   Pathology  (Continued) 62 

Metaplctsia. 

VIII.   Clinical 68 

IX.   Clinical  (Continued) ,      .       86 

Appendices ■ -     .     110 

TABLES 
I.   Carcinoma ,     .     114 

II.   Sarcoma ,      .     240 

III.  Doubtful 278 

IV.  Miscellaneous 314 


LIST  OF  ILLUSTRATIONS 

[The  Plates  Numbered  I  to  XVI  are  at  the  End  op  the  Volume] 

Frontispiece.  —  Section  of  lung,  showing  a  large  tumor  originating  from 
the  root  and  destroying  the  greater  part  of  lung.  Communicating  cavities 
and  tumor  nodules  of  varying  sizes.  That  portion  of  lung  not  infiltrated 
with  tumor,  compressed  and  pushed  backward  towards  the  spine. 

(From  a  drawing  by  H.  Becker.) 

Plate  I. — Transverse  section  across  an  infiltrating  tumor  and  adjoining  lung. 
Tumor  area  sharply  defined  against  lung  tissue.  Infiltration  so  dense  and 
complete  that  only  a  few  vessels  and  slightly  dilated  bronchi  are  visible  as 
remnants  of  normal  structure.     (From  a  drawing  by  H.  Becker.) 

Plate  II.  —  Shows  destruction  of  almost  entire  lung.  Pulmonary  tissue  almost 
completely  replaced  by  tumor.     (From  a  drawing  by  H.  Becker.) 

Plate  III.  —  Section  of  medullary  carcinoma  illustrating  the  occasional  impossi- 
bihty  of  differentiating  between  carcinoma  and  sarcoma. 

Plate  IV. — Same  section  as  preceding,  photographed  with  high  power,  ex- 
hibiting the  same  indeterminate  character. 

Plate  V. — Section  from  another  portion  of  the  same  tumor  as  shown  in  Plate 
IV.     In  structure  and  in  character  of  cells  plainly  suggesting  carcinoma. 

Plate  VI. — Shows  section  through  kidney  from  same  case.  An  incipient 
metastatic  deposit,  consisting  of  a  few  genuine  epithelial  cells  just  entering 
Bowman's  Capsule,  is  shown. 

Plate  VII.  —  Typical  picture  of  ordinary  form  of  carcinoma.  A  large  alveole 
is  seen,  directly  injecting  a  lymph- vessel  with  cancerous  cells. 

Plate  VIII.  —  Rapidly  proUferating  carcinoma,  suggesting  glandular  type. 
Very  little  stroma  between  the  alveoles,  which  latter  contain  mostly  flat 
and  cuboidal  epithelial  cells. 

Plate  IX.  —  Same  form  of  carcinoma.  Smaller  and  more  plexiform  alveolar 
structure,  more  voluminous  stroma,  injection  of  lymph-spaces  and  lymph- 
vessels  from  alveoles. 

Plate  X. — Cancroid  with  characteristic  homy  epithelial  nests. 

xi 


xii  LIST   OF   ILLUSTRATIONS 

Plate  XI. — Cylindrical-celled  carcinoma,  the  epithelium  not  ciliated.  Alveolar 
structm-e,  alveoles  varying  largely  in  size.  Much  mucoid  degeneration. 
Origin  from  bronchial  mucous  glands. 

Plate  XII. — Same  type  of  tumor.  To  the  right,  dilated  bronchus.  In  middle 
bronchial  mucous  glands,  transition  to  carcinomatous  alveoles  plainly  seen. 

Plate  XIII. — Similar  type  of  timior.  Shows  partial  destruction  of  bronchial 
cartilage  and  various  transitions  from  normal  bronchial  mucous  glands  to 
cancerous  alveoles. 

Plate  XIV. — Cylindrical-celled  carcinoma.  Suggestions  of  alveolar  structure. 
Striking  papillary  arrangement. 

Plate  XV.  —  Besides  alveolar  structure,  shows  marked  participation  of  lymph- 
vessels  and  spaces  in  the  cancerous  proliferation. 

Plate  XVI. — Shows  practically  only  affection  of  lymphatic  apparatus.  Both 
this  plate  and  the  one  preceding  represent  sections  taken  from  tumors  which 
in  other  localizations  show  typical  carcinomatous  structure. 


PEIMAEY  MALIGNANT   GEOWTHS 
OF  THE  LUNG 


PEIMAEY  MALIGNANT   GEOWTHS 
OF   THE   LUNG 

CHAPTER  I 
INTRODUCTORY 

IS  it  worth  while  to  write  a  monograph  on  the  subject  of 
primary  mahgnant  tmnors  of  the  Imig?  In  the  com'se  of 
the  last  two  centuries  an  ever-increasing  hteratiu-e  has  accu- 
mulated around  this  subject.  But  this  Hterature  is  without 
correlation,  much  of  it  buried  in  dissertations  and  other  out- 
of-the-way  places,  and,  with  but  a  few  notable  exceptions,  no 
attempt  has  been  made  to  study  the  subject  as  a  whole,  either 
the  pathological  or  the  cUnical  aspect  having  been  emphasized 
at  the  expense  of  the  other,  according  to  the  special  predilec- 
tion of  the  author.  On  one  point,  however,  there  is  nearly 
complete  consensus  of  opinion,  and  that  is  that  primary  mahg- 
nant neoplasms  of  the  lungs  are  among  the  rarest  forms  of 
disease.  This  latter  opinion  of  the  extreme  rarity  of  primary 
timaors  has  persisted  for  centuries.  Within  the  last  few 
decades  attempts  have  been  made  to  combat  this  dogma,  but 
even  now  the  overwhelming  majority  of  medical  practitioners 
rarely,  if  ever,  think  of  a  diagnosis  of  tumor  of  the  lungs,  and 
the  ubiquitous  tuberculosis,  with  its  multiform  clinical  appear- 
ances and  its  plastic  adaptation  to  all  ages  and  all  conditions 
of  mankind,  is  ever  ready  to  fxmiish,  to  all  but  a  very  few, 
a  comfortable  and  satisfactory  diagnosis. 

Most  textbooks  hardly  notice  lung  tumors,  and  if  they  give 
the  subject  any  consideration  it  is,  for  the  most  part,  insuf- 
ficient. Thus  the  well-known  and  still  authoritative  textbook 
on  Diseases  of  the  Lungs  and  Pleurae,  including  Tuberculosis 
and  Mediastinal  Growths,  by  Sk  R.  Douglas  Powell  and 

3 


4       PRIMARY  MALIGNANT  GROWTHS  OF  THE  LUNG 

P.  Horton-Smith  Hartley  (5th  Edition,  1911),  while  treating 
at  length  of  thoracic  tumors  and  of  mediastinal  tumors,  etc., 
has  scarcely  more  than  one  page  to  cover  the  entire  subject  of 
carcinoma  and  sarcoma  of  the  lungs.  The  excellent  book  of 
A.  Frankel  ^  and  the  admirable  chapters  on  carcinoma  of  the 
lungs  in  the  latest  edition  of  Wolff,  ^  as  well  as  a  few  other 
publications,^  attempt  a  more  comprehensive  presentation  of 
this  type  of  tumor,  but  they  seldom  get  into  the  hands 
of  the  medical  public  at  large,  and  so  it  happens  that  the 
general  practitioner  is  not  in  a  position  to  diagnosticate  a 
primary  lung  tumor  as  often  as  might  be,  and  the  belief  in 
the  extreme  rarity  of  these  cases  is  still  maintained.  To  add 
to  these  difficulties,  even  the  diagnoses  made  on  the  autopsy 
table  are  not  always  reliable.  There  are  still  careless  or  insuf- 
ficiently trained  persons  called  upon  to  do  this  rather  dehcate 
work.  It  may  happen  also  that  the  most  careful  and  search- 
ing autopsy  will  not  furnish  the  true  diagnosis  until  a  thorough 
microscopical  examination  has  been  made.  Take  for  example 
the  case  of  Walter  Kretschmar;  *  also  of  Morelli,^  This 
latter  case  is  remarkable  for  a  number  of  unusual  features: 
the  youth  of  the  patient,  —  a  female  aged  twenty-eight,  — 
the  sudden  onset  after  cold,  with  fever  and  cough,  the  clinical 
symptoms  of  a  pneumonic  consoUdation  in  right  base  with 
pleural  effusion  and  endocarditis.  The  sputum  showed  diplo- 
cocci.  On  autopsy  both  lungs  showed  white  nodules,  corre- 
sponding to  blood  vessels,  and  connective  tissue  strands  not 
infrequently  seen  after  pneumonic  processes.  No  tumor 
could  be  recognized,  and  only  upon  microscopic  examination 
were  nests  of  epithelial  cells  discovered  in  the  lymph  spaces 

1  Spezielle  Pathologie  u.  Therapie  der  Lungenkrankheiten,  1904. 

2  Die  Lehre  von  der  Krebskrankheit,  Vol.  II,  pp.  803  ff.,  Jena,  1911. 

'  Credit  must  be  given  here  to  Alfred  v.  Sokolowski,  Klinik  der  Brustkrank- 
heiten,  Vol.  I,  Berlin,  1906,  and  his  study  of  primary  malignant  and  non-malig- 
nant neoplasms  of  the  bronchi  and  lungs.  He  seems  to  consider  bronchial 
carcinoma  extremely  rare,  —  much  more  rare  than  primary  tumors  of  the  lung. 
He  has  a  chapter  of  about  fifteen  pages  devoted  to  lung  tumors,  citing  several 
cases  of  his  own  experience.  He  goes  rather  quickly  over  the  pathology  and 
diagnosis  of  carcinoma  and  in  the  same  way  hurries  over  sarcoma  without 
bringing  in  anything  notably  new. 

^  tjber  das  primare  Bronchial-  imd  Lungencarcinom,  Diss.  Leipzig,  1904. 

B  Table  I,  No.  201. 


INTRODUCTORY  5 

of  the  fibrous  tissue,  and  epithelial  clusters  in  the  alveoles  and 
in  the  alveolar  septa. 

Furthermore,  v.  Hansemann  ^  relates  that  in  his  experi- 
ence at  the  Friedrichshain  Hospital  there  were  711  carcino- 
mata  out  of  7790  autopsies,  of  which  156,  or  21.94%, 
were  not  diagnosticated  during  life,  not  even  as  tumors. 
Among  these  156  cases  there  were  sixteen  bronchial  and  pul- 
monary tumors.  Is  it  not  somewhat  humiliating  to  realize 
that  the  difficulties  of  diagnosis  are  still  so  great  as  to  pre- 
vent the  best  and  most  experienced  medical  men,  with  all 
the  advantages  of  a  large  hospital,  from  discovering  almost 
one-fifth  of  all  the  carcinomata  that  come  before  them?  If 
these  figures  hold  good  generally,  about  one-fifth  more  car- 
cinoma cases  should  be  added  to  our  ordinary  statistics. 
Another  important  addition  to  the  difficulties  to  be  contended 
with  lies  in  the  fact  that  in  many  countries,  as  for  example 
our  own,  justly  claiming  an  advanced  stage  of  civilization, 
the  overwhelmingly  great  majority  of  the  dead  are  not  sub- 
jected to  any  post-mortem  examination,  and  the  death 
certificates  on  which  burial  permits  are  officially  given  are 
often  ludicrously  insufficient.  For  this  reason  the  United 
States  Census  is  entirely  useless  for  our  purposes.  As  an 
example  of  the  misleading  diagnoses  and  insufficient  observa- 
tion which  hamper  one  in  getting  up  the  literature  of  this 
subject,  look  up  the  following:  Two  Cases  of  Melanotic 
Tumors  in  the  Lungs.^  Reliable  autopsies,  in  the  majority 
of  cases,  there  are  not,  and  many  autopsy  notes  that  have 
been  recorded  are  so  insufficient  in  their  data  and  descriptions 
that  a  conclusive  opinion  on  the  case  cannot  be  formed.  The 
same  applies  to  the  clinical  notes.  It  is  therefore  impossible 
to  say,  from  the  figures  given  by  the  United  States  Census 
concerning  causes  of  death,  how  many  persons  mentioned 
as  having  died  from  tuberculosis,  pneumonia,  or  kindred 
diseases,  may  not  really  have  died  from  lung  tumors. 

Considering  all    this,    it    seems    primarily   necessary   to 

^  Riechelmann,  Eine  Krebsstatistik  vom  pathologisch-anatomischen  Stand- 
punkt,  Berl.  Klin.  Woch.,  1902,  N.  31  and  32,  pp.  728  ff. 
2  Journal  A.  M.  A.,  1888,  p.  53. 


6       PRIMARY  MALIGNANT  GROWTHS  OF  THE  LUNG 

procure  enlightenment  on  the  question :  Are  malignant  tumors 
of  the  lung  as  rare  as  has  been  supposed?  And  if  they  are  not 
so  rare,  is  their  more  frequent  occurrence  due  to  a  supposed 
general  increase  in  the  incidence  of  malignant  growths? 
WilUams/  an  enthusiastic  exponent  of  the  increase  of  car- 
cinoma as  a  whole  and  the  corresponding  decrease  of 
tuberculosis,  supports  his  view  with  a  great  mass  of  statis- 
tical figures,  of  which  some  few  are  quoted  here. 


1840 


Incidence  in  England  and  Wales 
1905 


2786,  a  proportion  to  total 
number  of  deaths  of 
1:129,  or  177  per 
million  living. 


30221,  a  proportion  to  total 
number  of  deaths  of 
1:17,  or  885  per 
million  living. 


As  to  Newsholme's  contention  ^  that  the  registered  increase  is 
only  apparent,  being  actually  due  to  improved  methods  of 
diagnosis  and  death  certification,  WiUiams's  answer  is  that 
(1)  the  uniformity  in  increase  is  too  marked  to  be  due  to  im- 
proved diagnosis,  and  (2)  the  very  improvements  cited  have 
also  caused  subtractions  from  the  cancer  total,  since  many 
diseases  formerly  erroneously  called  cancer  are  now  given 
their  true  names.  Nencki  is  quoted  in  this  connection  *  as 
giving  the  increase  in  cancer  death-rate  in  Switzerland  from 
114  in  1889  to  132  in  1898  (per  100,000  living).  WilHams 
gives  the  following  figures  for  other  countries: 


Deaths  fbom  Cancer 


Paris,  France  1865 84 

1900  120 

Germany  1872 59 

1900  71 

Berlin      1870-1882  57 

1899  109 

Italy  1880  21 

1905  58 


United  States 

(per  100,000  Uving) 

1850.... 

....     9 

1900  . . . 

...43 

New  York 

1864  . . . 

...32 

1900  . . . 

...63 

Boston 

1863  . . . 

...28 

1903  . . . 

...85 

New  Orleans 

1864  . . . 

...15 

1903  . . . 

...82 

San  Francisco 

1856  . . . 

...16 

1900  . . . 

...112 

*  Natural  History  of  Cancer,  New  York,  1908. 
» Proceedings  of  the  Royal  Society,  1893,  Vol.  LFV,  p.  209. 
'  Die  Frequenz  und  Verteilung  des  Krebses  in  der  Schweiz,  etc.,  Zeitschr. 
f.  schw.  Statistik,  1900,  Vol.  II,  p.  332. 


INTRODUCTORY  7 

Other  important  statistical  work  to  be  consulted  is  that  of 
Robert  Behla/  the  great  standard  work,  in  four  volumes, 
of  Juliusburger,2  and  the  work  of  Newsholme.^  Looking 
carefully  over  these  statistics,  it  is  the  writer's  opinion  that 
the  statistics  of  Williams,  as  well  as  all  statistical  material 
thus  far  collected,  with  a  great  deal  of  care  and  labor,  have 
not  succeeded  in  proving  conclusively  that  there  is  a  real 
increase  in  the  incidence  of  cancer  and  a  corresponding 
decrease  in  the  incidence  of  tuberculosis.  The  fact  may 
turn  out  to  be  so,  but  at  this  writing  can  by  no  means 
be  considered  as  proven.  The  only  figiu-es  which  in  the 
course  of  time  will  give  us  the  means  of  definitely  solving 
problems  such  as  this  will  be  those  obtained  from  hospitals, 
where  the  material  is  more  uniform,  where  the  best  modem 
methods  of  observation  and  diagnosis  are  applied,  and  where 
finally  the  autopsies  and  microscopical  examinations  are  done 
with  the  utmost  care.  Reports  of  life  insurance  officers,  statis- 
tics taken  from  books  of  registrars  and  recorders,  where  only 
the  causes  of  death  are  mentioned,  cannot  be  effectively 
utilized. 

It  has  been  shown,  especially  by  the  researches  of  Behla 
just  quoted,  that  some  sort  of  influence  of  occupation  or 
trade  may  possibly  be  considered  a  factor  in  the  incidence 
of  carcinoma.  If  so,  this  factor  is  of  very  slight  significance 
and  may,  at  least  for  the  study  of  lung  tumors,  be  entirely 
disregarded. 

It  is  the  conviction  of  the  writer,  and  he  shares  this  belief 
with  many  others,  —  the  mention  of  whose  names  and  criti- 
cism of  whose  work  need  not  be  entered  upon  here,  —  that 
there  is  no  absolute  increase  in  the  incidence  of  carcinoma. 
Nevertheless,  the  incidence  of  malignant  neoplasms  of  the 
lungs  seems  to  show  a  decided  increase.  It  has  been  stated 
that  statistical  research  in  this  direction  is  beset  with  many 
difficulties.    It  may  be  hoped  that  in  the  course  of  a  few 

^  Krebs  und  Tuberkulose  in  beruflicher  Beziehung  vom  Standpunkte  der 
vergleichenden  internationalen  Statistik,  Berlin,  1910. 

^  Die  Krankheits-  und  Sterblichkeitsverhaltnisse  in  der  Ortskrankenkasse 
fiir  Leipzig  und  Umgegend. 

'  The  Statistics  of  Cancer,  The  Practitioner,  April,  1899. 


8       PRIMARY  MALIGNANT  GROWTHS  OF  THE  LUNG 

years  accurate  and  reliable  figures  will  be  available.  In  the 
meantime,  however,  the  following  table,  founded  on  figures 
collected  by  Karrenstein  ^  and  considerably  amended  and 
enlarged,  will  at  least  serve  to  show,  not  the  causes,  but  the 
fact  of  the  apparent  increase.    It  is  very  significant  that  in 

Primart  Carcinoma  of  the  Lungs  and  Bronchi 


I 

II 

in 

IV 

V 

VI 

VII 

Time 

Place 

%  of  all 

Total 

%  of  aU 

Total 

Author 

Carci- 

No. 

Autop- 

No. of 

noma 

Carci- 
noma 
Cases 

sies 

Autop- 
sies 

1.  1852-67 

Stadtkrankenhaus, 
Dresden 

0.91 

8716 

Reinhardt^ 

2.  1852-1908 

Patholog.  Institut, 
Wurzburg 

15  or 
0.93 

1607 

Fockler ' 

3.  1854-85 

Stadtkrankenhaus, 
Mtinchen 

8  cases 

0.065 

12307 

Fuchs* 

4.  1870-88 

Patholog.  Institut  der 
Universit .  Kolozsvar 

0 

145 

Buday  ^ 

5.  1872-89 

Patholog.  Institut, 
Bern 

2 
0.42 

474 

0.059 

3363 

C.  Miillers 

6.  1872-98 

Reichsgesundheits- 
amt,  Hamburg 

84 
0.70 

11930 

0.02 

336486 

Reiche' 

7.  1873-87 

Patholog.  Institut, 
Kiel 

0 

Danielsen  ^ 

8.  1877-84 

Stadtkrankenhaus, 
Dresden 

9  cases 

0.22 

4712 

Wolfs 

9.  1881-94 

Patholog.  Institut, 
Breslau 

1.83 

870 

9246 

Passler^" 

10.  1885-94 

Stadtkrankenhaus, 
Dresden 

31 

cases 

0.43 

7728 

Wolf  11 

1  Charit^-Annalen,  Berlin,  1908. 

2  Reinhardt,  Der  primare  Lungenkrebs,  Arch.  f.  Heilkunde,  XIX,  1878.-2. 
^  Fockler,  Krebsstatistik  nach  den  Befunden  des  patholog.  Instituts  zu 

Wurzburg,  Diss.  Wiirzburg,  1909. 

^  Fiichs,  Beitr.  zur  Kenntnis  der  Geschwiilstbildungen  in  der  Lunge,  Diss. 
Miinchen,  1886. 

^  Buday,  Statistik  der  im  patholog. -anatom.  Institut  der  Universitat  Koloz- 
svar usw.  Zeitschr.  f.  Krebsforschung,  Vol.  VI,  S.  7. 

'  Miiller,  C,  Beitrag  zur  Statistik  der  malignen  Tumoren,  Diss.  Bern,  1890. 

^  Reiche,  Beitrage  zur  Statistik  des  Carcinoms,  Deut.  Med.  Woch.,  1900, 
N.  7,  p.  120  ff. 

8  Danielsen,  Quoted  from  Schlereth,  2  FaUe  von  primarem  Lungenkrebs, 
Diss.  Kiel,  1888. 

9  Wolf,  Fortschritte  der  Medizin,  1895. 
10  Passler,  s.  S.  315,  No.  5. 

"  Wolf,  loc.  cit. 


INTRODLXTORY  9 

Primary  Carcinoma  of  the  Lungs  and  Bronchi  —  Continued 


I 

II 

III 

IV 

V 

VI 

VII 

Time 

Place 

%■  of  all 

Total 

%of  aU 

Total 

Author 

Carci- 

No. 

Autop- 

No. of 

noma 

Carci- 
noma 
Cases 

sies 

Autop- 
sies 

11.  1886-96 

Krankenhaus, 
Munchen 

9 
1.2 

706 

0.10 

8727 

Periitzi 

12.  1887-1906 

Patholog.  Institut, 
Wien 

68 

0.17 

40000 

Haberfeld2 

13.  1888-97 

Patholog.  Institut, 
Greifswald 

1.78 

Kaminski^ 

14.  1888-1905 

Patholog.  Institut, 
Universit.  Kolozsvar 

10 

4.5 

221 

Buday  * 

15.  1895-1901 

Friedrichshain,  Berlin 

711 

7790 

Riechelmann  ^ 

16.  1899-1903 

Patholog.  Lab. 
Lubarsch,  Posen 

3 
1.2 

159 

0.17 

1741 

Sehrte 

17.  Vor  1900 

Patholog.  Institut 
am  Urban-BerUn 

4 

100 

0.4 

Feilchenfeldt^ 

18.  1899-1904 

Patholog.  Institut 
am  Urban-Berlin 

0.6 

Benda^ 

19.  Zeitraum 

Patholog.  Institut, 

20 

Rieck  9 

V.  10  Jahr. 

Univ.  Miinchen 

1.92 

20. 

6 
1.3 

447 

Lebertio 

21.  1900 

Patholog.  Institut, 
Charit^Berlin 

2.91 

3  cases 

103 

0.23 

1300 

Karrenstein  i^ 

22.  1900-05 

Urban-Berlin 

31 
0.61 

496 

0.6 

5002 

Redlichi2 

23.  1901 

Patholog.  Institut, 
Charity-Berlin 

8.86 
7  cases 

79 

0.53 

1310 

Karrenstein" 

^  Perutz,  Zur  Histogenesis  des  primaren  Lungenkarzinoms,  Diss.  Miinchen, 
1897. 

^Haberfeld,  Carcinom  des  Magens,  der  Gallenblase  und  Bronchien. 
Z'tschrift  f.  Krebsforsch.,  Vol.  VII,  I.  Fasc,  p.  204. 

3  Kaminski,  s.  S.  315,  No.  6. 

*  Buday,  loc.  cit. 

^  Riechelmann,  Eine  Krebsstatistik  von  path.-anatom.  Standpunkt,  Berl. 
klin.  Woch.,  1902,  N.  31  and  32,  pp.  728  ff. 

^  Sehrt,  Beitrage  zur  Kenntnis  des  primaren  Lungenkarzinoms,  Diss.  Leip- 
zig, 1904. 

7  Feilchenfeldt,  Quoted  from  Benda,  Deut.  Med.  Woch.,  1904,  S.  1454. 
Beitrage  zur  Statistik  und  Kasuistik  des  Karzinoms,  Diss.  Leipzig,  1901  (after 
Redlich). 

8  Benda,  loc.  cit.,  S.  1453. 

5  Rieck,  Krebsstathstik  nach  den  Befunden  des  patholog.  Instituts  zu 
Miinchen,  Diss.  Munchen,  1904. 

1"  Lebert,  Traits  pratique  des  Maladies  cancereuses. 

"  Karrenstein,  Charite-Annalen,  XXXII  Jahrg.,  Berlin,  1908. 

12  Redlich,  Die  Sektions-Statistik  des  Carcinoms,  etc.,  am  Stadt-Kranken- 
haus  am  Urban,  1900-1905,  Diss.  Berlin,  1907. 


10     PRIMARY  MALIGNANT  GROWTHS  OF  THE  LUNG 

Primary  Carcinoma  of  the  Lungs  and  Bronchi  —  Continued 


I 

II 

III 

IV 

V 

VI 

VII 

Time 

Place 

%  of  all 

Total 

%  of  aU 

Total 

Author 

Carci- 

No. 

Autop- 

No. of 

noma 

Carci- 
noma 
Cases 

sies 

Autop- 
sies 

24.  1902 

Patholog.  Institut, 
Charity-Berlin 

3.23 
3  cases 

93 

0.31 

999 

Karrenstein^ 

25.  1903 

Patholog.  Institut, 
Charite-BerUn 

3.19 
3  cases 

94 

0.24 

1272 

Karrenstein  ^ 

26.  1904 

Patholog.  Institut, 
Charite-Berlin 

2.67 
4  cases 

150 

0.28 

1399 

Karrenstein  ^ 

27.  1905 

Patholog.  Institut, 
Charite-Berlin 

0.71 
1  case 

140 

0.08 

1313 

Karrenstein^ 

28.  1906 

Patholog.  Institut, 
Charite-Berlin 

4.84 
6  cases 

124 

0.46 

1319 

Karrenstein^ 

29.  1906-08 

Krankenhaus,  r.  d.  I., 
Manchen 

174 

0.18 

945 

Forstner^ 

30.  1907 

Patholog.  Institut, 
Charite-Berlin 

3.31 

5  cases 

151 

0.37 

1360 

Karrenstein  1 

31.  1908 

Stadtkrankanstalten, 
Hamburg 

11 
1.2 

920 

Korber' 

32.  1908-09 

Patholog.  Institut 
Krankenhaus, 
Miinchen 

1.8 

212 

0.29 

1371 

Nobiling^ 

33. 

Basel 

1.76 

Kauf  mann  ^ 

34.  1910-11 

Charity- Annalen, 
Berlin 

0.76 

141 

0.05 

185 

Orth6 

1900  the  Pathological  Institute  of  the  Charite  in  Berlin 
recorded  only  three  cases  of  lung  tumor,  while  in  1906  and 
1907  five  and  six  cases  respectively,  were  recorded.  It  is 
more  significant  still  when  the  reports  of  the  Pathological 
Institute  of  Kolozsvar  from  1870  to  1880  and  from  1888  to 
1905  respectively,  are  compared.  It  is  to  be  remembered  that 
this  table  is  made  up  mainly  from  records  of  pathological 
laboratories  of  fairly  high  standing. 

There  seems  hardly  room  for  doubt  that  the  increase  in 
the  percentage  of  lung  tumors  is  to  be  attributed  mainly  to 

^  Karrenstein,  Charitl-Annalen,  XXXII  Jahrg.,  Berlin,  1908. 

2  Forstner,  tjber  maligne  Tumoren,  Diss.  Miinchen,  1908. 

'  Korber,  Die  Ergebnisse  der  Hamburgischen  Krebsforschung  im  Jahre 
1908.     Mitt.  Hamburgischen  Staatskrankenanstalten,  Vol.  IX,  Supp.,  1908. 

*  Nobihng,  Z'tschrift  f .  Krebsforsch.  patholog.  Institut  Krankenhaus, 
Miinchen,  r.  d.  I.,  1908-1909. 

'  Kaufmann,  Lehrbuch  der  Spec.  Path.  Anatomie,  Basel,  1909. 

6  Orth,  Charit6-Annalen,  Berlin,  XXXV  Jahrg.,  1911. 


INTRODUCTORY  11 

the  increased  attention  paid  to  these  types  of  tumor  and  the 
greater  care  and  more  extensive  microscopic  investigation 
with  which  autopsies  are  carried  out  at  present.  As  early 
as  1837,  Stokes  ^  had  aheady  remarked  that  in  his  experience 
lung  tumors  are  by  no  means  as  rare,  either  in  England  or  in 
Ireland,  as  was  generally  assumed,  and  Boyd  ^  even  goes  so 
far  as  to  assert  that  primary  cancer  is  more  frequent  in  lungs 
than  secondary  cancer,  an  assertion  which  he  explains  as 
follows :  ''A  case  of  maUgnant  deposit  in  the  bronchial  glands, 
infiltrating  the  lung,  ending  in  ulceration  and  the  formation 
of  cavities,  is  frequently  set  down  as  one  of  hopeless  phthisis, 
a  post-mortem  on  which  would  be  of  no  interest,  and  all 
record  of  the  frequency  of  the  disease  is  in  consequence 
entirely  lost."  This  utterance  of  Boyd's  is  probably  some- 
what of  an  exaggeration,  for  while  it  has  just  been  shown 
that  the  behef  in  the  extreme  rarity  of  lung  tumors,  a  lusus 
naturae,  as  it  were,  can  no  longer  be  maintained,  it  must  be 
conceded  that  these  tumors  belong  to  the  class  of  rarer 
neoplasms  and  their  incidence  is  out  of  all  proportion  to  the 
frequency  of  occurrence  of  other  malignant  neoplasms,  as  for 
example  of  the  female  breast  or  the  stomach. 

Seeing,  thus,  that  lung  tumors  are  to  be  reckoned  with  more 
often  than  was  formerly  believed,  it  is  to  be  expected  that 
nimierous  problems,  both  pathological  and  clinical,  will 
present  themselves.  Besides  these  problems  of  purely  theo- 
retical interest  to  the  pathologist  and  the  clinician,  there  is 
the  great  importance  to  the  patient  of  a  correct  diagnosis. 
It  cannot  be  a  matter  of  indifference  to  the  unfortunate 
sufferer  whether  his  case  be  diagnosticated  as  tuberculosis 
or  as  tumor.  If  tuberculosis,  he  will  be  sent  from  one  climate 
and  one  sanitarium  to  another,  he  and  his  family  possibly 
deluded  with  false  hopes,  until  finally  secondary  symptoms 
have  cleared  up  the  case  and  death  has  brought  relief.  The 
grave  prognosis  which  is  an  integral  part  of  the  diagnosis  of 
tumor  may  be  of  paramount  importance  to  the  patient  as  well 
as  to  his  relatives.    At  all  events,  so  much  is  certain,  that  if 

1  Diseases  of  the  Chest,  London,  1837. 

2  Table  I,  No.  46. 


12     PRIMARY  MALIGNANT  GROWTHS  OF  THE  LUNG 

the  diagnosis  of  lung  tumors  is  to  be  developed  so  as  to  render 
it  more  precise,  and  if  any  reasonable  attempt  is  to  be  made  to 
convert  the  present  desperate  prognosis  into  one  less  hopeless, 
this  great  result  can  only  be  achieved  if  the  internist  shall 
work  hand  in  hand  and  shoulder  to  shoulder  with  the  surgeon. 
The  internist  must  be  able  to  furnish  as  early  and  as  accurate 
a  diagnosis  as  possible,  so  that  the  surgeon  under  favorable 
conditions  may  develop  his  technique  as  early  as  possible. 
With  these  few  introductory  words,  the  initial  question,  it  is 
dared  to  hope,  is  answered  affirmatively. 


CHAPTER  II 

IN  TROD  UCTOR  Y  {Continued) 

IN  undertaking  to  write  this  monograph,  it  is  proposed  to 
present  the  subject  and  the  problems  connected  therewith 
in  as  comprehensive  and  at  the  same  time  as  concise  a  manner 
as  possible.  Not  only  carcinoma,  but  the  other  malignant 
tumors  of  the  lung  are  to  be  presented,  both  from  a  broad 
pathological,  as  well  as  from  a  clinical  point  of  view. 

As  the  first  step  toward  the  accomplishment  of  this  end, 
it  was  found  necessary  to  collect  a  very  large  material  from 
the  literature.  Thus  far,  but  comparatively  few  cases  had 
been  picked  up.  Passler,^  after  much  sifting,  managed  to 
collect  about  seventy-four  cases  of  undoubted  primary  car- 
cinoma of  the  lungs.  This  was  in  1896,  just  fifteen  years 
ago.  The  latest  publication  ^  casually  remarks  that  about 
one  hundred  cases  may  now  be  found  in  literature.  The 
difficulties  of  collecting  cases  in  point  have  already  been 
hinted  at.  It  is  extremely  trying  to  delve  into  all  sorts  of 
doctor-dissertations,  obscure  and  forgotten  publications  of 
all  kinds  and  in  all  languages,  to  be  frequently  rewarded  by 
finding  that,  after  all,  the  case  is  secondary,  or  is  not  a  case  in 
point  at  all,  or  that  no  autopsy  was  made,  or  that  no  micro- 
scopic examination  was  reported.  Again,  no  clinical  history 
is  given,  and  the  pathological  diagnosis,  though  modern  and 
very  good,  is  not  sufficiently  supported  by  clinical  observa- 
tions. The  collection  of  cases  from  modern  times  has  been 
simplified  by  the  introduction  of  the  microscope  into  pathol- 
ogy and  the  nomenclature  of  tumors  based  on  microscopic 

lyirch.  Arch.,  Vol.  145,  1896,  p.  191. 

2  Edward  Boecker,  Zur  Kenntnis  der  primaren  Lungenkarzinome,  Dies. 
Gottingen,  Berlin,  1910. 

13 


14     PRIMARY  MALIGNANT  GROWTHS  OF  THE  LUNG 

study,  which  latter,  though  not  fulfilling  all  demands,  is  most 
helpful.  But  even  within  the  last  two  years,  reports  have  been 
pubhshed  where  there  is  no  autopsy  at  all,  or  one  that  is  very 
insufficient,  and  the  microscopic  examination  is  either  absent 
or  summarized  in  such  general  terms  as  "simple  carcinoma," 
etc.  Nevertheless,  though  it  has  taken  several  years  in  the 
compiling,  374  cases  of  carcinoma  have  been  collected.  It  was 
thought  best  to  make  full  abstracts  wherever  possible,  so  that 
the  principal  data  of  each  case,  both  clinical  and  pathological, 
may  be  at  the  disposal  of  the  reader,  enabling  him  to  use  his 
own  judgment  and  form  his  own  deductions.  The  same  has 
been  done  for  sarcoma,  though  the  latter  is  infinitely  more 
difi&cult  to  get  at  than  carcinoma,  —  not  only  because  sarcoma 
is  so  much  rarer,  as  will  be  seen,  but  because  very  many  cases 
are  published  without  sufficient  autopsy,  and  even  if  autopsied 
the  almost  intolerable  confusion  in  the  nomenclature  makes 
the  diagnosis  from  the  printed  case  wellnigh  impossible. 

A  third  collection  has  been  made  which  contains  cases  desig- 
nated as  doubtful,  though  many  of  them  may  be  authentic 
and  valuable.  They  have  been  classed  as  doubtful  for 
various  reasons,  sometimes  because  the  autopsy  was  lacking, 
though  the  clinical  observations  pointed  almost  with  certainty 
to  a  tumor  diagnosis,  or  it  was  impossible  to  decide  whether 
the  case  was  one  of  carcinoma  or  sarcoma,  etc. 

A  few  other  cases  have  been  assembled  which,  properly 
speaking,  do  not  belong  to  the  subject  in  hand,  but  which  may 
in  their  symptoms  during  life  so  closely  resemble  primary 
growths  of  the  lung  that  it  was  thought  wise  to  place  them 
here  for  warning  and  for  comparison. 

The  reader  should  well  understand  that  no  claim  is  made 
for  absolute  completeness.  Many  cases  were  not  taken  into 
our  collection  either  because  they  were  not  obtainable,  or 
were  written  in  a  language  that  could  not  be  readily  trans- 
lated, or  for  other  reasons.  Besides  this,  too,  it  was  imprac- 
ticable to  continue  collecting  material  indefinitely,  and  since 
the  collection  of  material  has  been  discontinued  numerous 
cases  have  been  published,  which  could  not  appear  in  the 
present  collection.    It  may  be  stated  also  that,  with  the 


INTRODUCTORY   (Continued)  15 

exception  of  but  comparatively  few,  the  references  were  read 
and  excerpted  personally.  This  rather  bulky  collection  is 
printed  in  the  form  of  tables,  the  first  and  largest  being  of 
carcinoma  cases;  the  second,  sarcoma;  the  third,  doubtful; 
and  the  fourth,  a  few  miscellaneous  cases. 


CHAPTER  III 

A  FEW  HISTORICAL  NOTES 

Precancerous  Influences 

OUR  knowledge  of  lung  tinnors  dates  from  comparatively 
recent  times,  and  the  history  of  its  development  can  be 
sketched  in  a  very  few  words.  It  may  aptly  be  divided  into 
several  periods.  In  the  first  and  longest  period,  lung  tumors 
were  absolutely  unknown.  This  period  includes  all  of 
ancient  and  mediaeval  medicine  until  Morgagni  ^  (1682-1772) 
laid  the  foundations  of  pathological  anatomy.  It  is  most 
interesting  and  significant  that  Morgagni  himself  was  prob- 
ably the  first  to  publish  the  results  of  several  autopsies  on 
lungs  that  might  be  diagnosticated  as  cancerous,  and  were 
so  interpreted  by  him.  It  is  probable  that  the  first  of  the 
cases  which  he  published  as  cancer  of  the  lungs  was  really  a 
case  of  primary  lung  tumor.  In  this  case  he  describes  the 
disease  of  a  man  sixty  years  old,  which  was  accompanied  by 
cough  and  copious  expectoration  of  a  yellowish,  rather  crude 
material,  rarely,  but  then  distinctly,  stained  by  streaks  of 
blood.  At  autopsy  the  lung  was  foimd  extremely  hard, 
adhesions  to  pleura  and  mediastina,  and  nothing  else  but 
an  "ulcus  cancrosiun"  in  the  right  lung.^  The  oft-quoted 
observations  of  Lieutaud  ^  deal  probably  with  tuberculosis 
or  diseased  pleura,  and  not  with  tumor.  The  cases  mentioned 
by  Van  Swieten  *  must  also  be  considered  extremely  doubtful. 

1  De  Sedibus  et  Causis  Morborum  per  Anatomen  indigatis. 

2  Loc.  cit. 

'  Historia  anatomico-medica,  etc.,  Paris,  1767,  Lib.  II. 
*  Comment,  ad  Boerhaavi  Aphorism,  Vol.  II,  1747. 
16 


A  FEW  HISTORICAL  NOTES  17 

There  are  a  number  of  French  authors  about  this  time  ^  who 
pubhshed  cases  as  cancerous  that  cannot  be  distinguished 
with  certainty  from  tuberculosis.  G.  L.  Bayle^  pubhshed 
thi'ee  cases  which  he  had  carefully  studied  clinically  and 
equally  carefully  after  death,  and  he  is  the  author  of  the 
phrase  "phthisie  cancereuse"  which  caused  so  much  discus- 
sion. The  first  case  he  reports  may  possibly  be  a  primary- 
tumor,  although  this  is  doubtful.  The  second  case  is  cer- 
tainly secondary  after  amputation  of  the  arm.  The  third  case 
was  that  of  a  man  seventy-two  years  old,  in  which  there  were 
found  at  autopsy,  at  the  root  of  the  lung,  shining  white 
encephaloid  cancerous  masses,  which  were  associated  with 
masses  of  tuberculosis.  It  is  unnecessary  to  go  into  all  the 
clinical  and  pathological  details  and  theories  on  which  Bayle 
bases  his  conclusions.  There  is  some  merit  in  his  insistence 
that  cancer  and  tuberculosis  may  exist  together,  although  the 
tubercles,  according  to  him,  are  the  effect  of  an  acid,  and 
cancer  the  effect  of  an  alkali.  No  clear  idea,  however,  can  be 
obtained  of  what  he  means  by  cancer  and  what  by  tubercu- 
losis, and  it  consequently  happened  altogether  too  frequently 
that  his  followers  accepted  true  tubercular  cavities  as  can- 
cerous, and  vice  versa,  so  that  finally  great  confusion  arose 
as  between  tubercular  phthisis  and  cancerous  phthisis.  His 
contention  that  cancer  of  the  lungs  may  exist  for  a  very  long 
time  without  any  symptoms  has  been  corroborated  by  modem 
medicine.  On  the  other  hand,  he  makes  no  distinction 
between  primary  and  secondary  tumor. 

Besides  the  French,  a  number  of  German  authors  have 
worked  on  fines  similar  to  those  of  Bayle,  and  though  the 
name  "phthisie  cancereuse"  could  not  maintain  itself  for  a 
very  long  period,  the  name  "fungus  hsematodes,"  or  simply 
"fungus  of  the  lung," — especially  among  German  writers, — 
was  used  for  all  pulmonary  neoplasms  that  bore  a  suspicion 
of  mafignancy.    Those  seeking  further  information  of  these 


1  Le  Dran,  Mem.  de  I'Acad.  royale  de  Chir.,  Vol.  Ill,  p.  28,  Obs.  22.     Also 
J.  F.  Senaux,  fils. 

2  Journal  de  Medicine,  Tome  73,  1787.     Also  Recherches  sur  la  Phthisie 
pulmonaire,  Paris,  1810,  p.  299.     Also  Diet,  de  Science  m6d.,  Paris,  1810. 

3 


18     PRIMARY  MALIGNANT  GROWTHS  OF  THE  LUNG 

historical  questions  are  referred  to  the  EngUsh  classics,  espe- 
cially Stokes/  Graves,^  and  Walshe;^  and  also  to  the,  for 
that  period,  very  complete  and  thorough  works  of  Reinhold 
Kohler,^  and  among  modern  authors,  J.  Wolff.  ^ 

With  Bayle  and  his  followers  ends  the  second  period,  and 
we  enter  upon  the  third,  characterized  by  the  study  of  lung 
tumors  by  purely  clinical  methods,  reenforced  by  gross 
pathological  anatomy.  This  period  is  introduced  by  Laennec, 
the  author  of  TAuscultation  Mediate,  who,  with  his  great 
authority  and  keen  mind,  took  up  the  combat  against  Bayle 
and  his  after  all  not  very  progressive  theories  of  the  "phthisie 
cancereuse"  and  successfully  differentiated  the  carcinoma  of 
the  lungs,  whether  primary  or  secondary,  from  any  form 
of  phthisical  process,  even  though  cavities  should  be  found 
coimected  with  the  tumor.  He  described  tumor  of  the  lung 
in  the  clearest  terms,  under  the  designation  ''encephaloid." 
The  use  of  this  term,  appUed  promiscuously  to  all  sorts  of 
tumors,  caused  considerable  confusion  imtil  Virchow  worked 
out  a  rational  classification. 

Since  the  time  of  Laennec,  his  lifework,  the  practice  and 
perfection  of  the  methods  of  auscultation  and  percussion,  has 
been  assiduously  continued  and  by  these  means  a  compara- 
tively large  number  of  lung  tumors  has  been  diagnosticated 
and  reported.  For  a  long  time  the  necessary  distinction 
between  primary  and  secondary  tumors  was  not  upheld,  and 
a  number  of  cases  were  insufficiently  observed  and  carelessly 
reported,  but  still  progress  in  the  diagnosis  of  primary  tumor 
of  the  lungs  was  certainly  made.  J.  Bell  ^  is  said  to  have  been 
the  first  to  diagnosticate  with  certainty  a  primary  tumor, 
which  was  undoubtedly  sarcoma  of  the  lung.  The  real 
founder  of  this  school  is  Stokes,  who,  together  with  Graves, 
Walshe,  Hughes,  and  others,  laid  the  foundations  of  our 
present  clinical  and  pathological  knowledge  of  primary  lung 

'  Loc.  cit. 

2  Clinical  Lectures  on  the  Practice  of  Medicine,  London,  New  Sydenham 
Soc,  2d  Ed.,  Dublin,  1848,  by  J.  Moore  Neligan. 

^  A  Practical  Treatise  on  Diseases  of  the  Lung,  etc.,  4th  Ed.,  London,  1871. 

*  tJber  den  Lungenkrebs,  Diss.  Tubingen,  1847,  and  Die  Krebs-  und  Schein- 
krebskrankheit  des  Menschen,  Stuttgart,  1853. 

6  Loc.  cit.  6  Table  II,  No.  3. 


A  FEW  HISTORICAL  NOTES  19 

tumors.  Following  upon  this  period  of  purely  clinical  and 
gross  pathological  observation,  there  comes  the  time  when, 
after  the  fundamental  discovery  of  Schwann,  histology  be- 
comes the  main  factor  in  pathological  research.  After  the 
great  work  of  Rokitansky,^  in  gathering  together  a  very  large 
material  which  led  to  a  general  cleaning-up  and  reclassifying 
of  pathological  anatomy,  it  is  above  all  the  name  and  work 
of  Virchow  that  dominate  this  entire  epoch.  He  was  the  first 
to  demand  that  medicine  be  lifted  out  of  a  maze  of  hypotheses 
and  more  or  less  plausible  theories  to  become  one  of  the 
natural  sciences,  based  on  critical  observation  and  experiment. 
The  "cellular  pathology,"  with  its  battle-cry  of  "Omnis 
cellula  e  cellula,"  exercised  great  influence  on  the  study 
of  tumors.  The  entire  onkology  was  taken  up  again  and 
rearranged  in  the  light  of  the  fact  that  every  cell  origi- 
nated, not  from  blastema,  not  from  plastic  lymph,  not 
from  diatheses  or  other  exogenic  processes,  but  from  cells 
alone.  2  The  present  time  is  still  a  part  of  this  period, 
and  the  study  of  lung  tumors  must  be  continued  along  these 
lines. 

Notwithstanding  the  great  amount  of  work  that,  as  has 
just  been  shown,  has  been  done  and  is  still  going  on,  Williams^ 
is  probably  correct  when  he  makes  the  somewhat  brusque 
statement  that  "it  is  necessary  at  the  outset  to  refer  thus 
pointedly  to  the  crudeness  and  immaturity  of  medical  knowl- 
edge, because  nowhere  do  these  qualities  find  more  striking 
exemplification  than  in  the  terrible  welter  of  disjointed  facts 
and  contradictory  hypotheses  that  constitute  such  a  large 
part  of  modern  Humor  science.'"  There  cannot  be  any 
intention  to  discuss  here  the  multitude  of  questions  and  prob- 
lems concerning  the  etiology  and  the  true  natm^e  of  malignant 
growths  in  general.  The  many  questions  of  fundamental 
import,  the  attempts  into  the  field  of  etiology,  the  innumerable 

^  Lehrbuch  der  pathol.  Anatomie,  1844. 

2  Thiersch,  Der  Epithelialkrebs  namentlich  der  Haut,  Leipzig,  1865;  Wal- 
deyer,  Uber  den  Krebs,  Volkmanns  Samml.,  1873,  No.  33;  Bard,  La  Specificity 
cellulaire  et  I'Histologie  chez  I'embryo,  Arch,  de  Phys.  normal,  et  path.,  3  Ser., 
7,  p.  406,  the  author  of  the  aphorism:  "Omnis  cellula  e  cellula  ejuedem 
generis."  '  Loc.  cit. 


20     PRIMARY  MALIGNANT  GROWTHS  OF  THE  LUNG 

theories,  and  above  all,  the  enormous  experimental  work  that 
has  been  done  within  recent  years,  —  all  this  is  obviously 
beyond  the  scope  of  this  little  monograph,  which  is  to  be 
devoted  solely  to  the  study  of  lung  tumors. 

Nearly  all  the  types  of  malignant  neoplasms  that  occur  in 
other  parts  of  the  body  are  also  to  be  found  among  the 
primary  growths  of  the  lung,  but  before  taking  up  the  direct 
study  of  these  tumors,  some  attention  should  be  given  to 
the  conditions  which  have  long  been  called  "predisposing 
causes,"  but  which  latterly  and  more  significantly  are  termed 
'^ precancerous  conditions  and  affections."^ 

First,  the  influence  of  race  on  carcinoma.  According  to  the 
latest  statistics,  race  and  geographical  distribution  seem  to 
have  a  decided  influence  on  the  incidence  of  malignant 
growths.2  In  the  very  thorough  work  of  Dr.  Levin,^  sufficient 
proof  appears  to  be  found  that  there  is  less  cancer  among  the 
American  Indians  and  American  negroes  than  among 
the  whites.  Tuberculosis  decimates  the  American  Indians, 
while  they  are  almost  immune  to  cancer.  This  seems  to 
contradict  the  statistical  conclusions  arrived  at  by  Behla.^ 
Levin  notes,  too,  that  it  is  usually  sarcoma  or  epithelioma 
of  the  different  external  parts  of  the  body,  which  are  neces- 
sarily more  exposed  to  mechanical  irritations,  that  affect  the 
primitive  races.  In  civilized  nations  there  is  a  prevalence 
of  carcinoma  of  the  internal,  parenchymatous  organs.  The 
following  sentence,  quoted  from  Levin,  is  important:  "Thus 
the  conclusion  is  forced  on  one's  mind  that,  while  every 
human  being  may  carry  within  himself  the  X  which  may 
develop  into  cancer,  it  is  the  modern  civilization  and  the 
conditions  created  by  it  that  give  rise  to  the  mediate  causes 
which  produce  the  disease."  The  facts,  indeed,  at  present 
available,    support   the    conclusion    that   the   white   races, 

1  All  these  data  and  figures  have  evidently  been  worked  out  principally  for 
carcinoma,  sarcoma  being  brought  in  now  and  then  incidentally  only,  probably 
because  of  its  rarity,  possibly  because  no  difference  was  made  between  the 
two. 

2  Carl  Lewin,  Die  Bosartigen  Geschwiilste,  Leipzig,  1909.  Also  Williams, 
loc.  cit. 

'  I.  Levin,  Cancer  among  the  American  Indians,  Zeitschr.  f.  Krebsforsch., 
Vol.  X,  Heft  II,  1911.  ^  Loc.  cit. 


A  FEW  HISTORICAL  NOTES  21 

especially  in  Europe  and  the  United  States,  can  claim  the 
greatest  mortality  from  malignant  growths,  and  there  is 
only  China,  perhaps,  that  can  compete  with  them  in  this 
respect.  It  is  reasonable  to  suppose  that  this  applies  also 
to  lung  tumors,  though  there  are  no  special  statistics. 

Next,  the  question  of  heredity.  This  has  always  been 
considered  a  very  potent  factor  in  the  etiology  of  malignant 
neoplasms  in  general.  Josefson  and  Pfannenstill  ^  have 
already  noticed,  however,  that  this  does  not  apply  to  lung 
tumors.  They  have  found  only  one  case  of  accredited  hered- 
ity among  their  seventy  cases.  According  to  Table  I,  in  290 
cases  of  carcinoma  heredity  is  not  mentioned.  As  many  of 
these  cases  are  very  superficially  reported,  and  as  in  many 
others  no  clinical  history  is  given,  but  the  cases  are  simply 
introduced  as  pathological  specimens,  it  is  likely  that  among 
these  290  cases  there  may  be  many  where  the  factor  of  hered- 
ity was  simply  overlooked.  In  twelve  cases  only  it  was  posi- 
tively stated  that  there  was  a  hereditary  strain  of  cancer  in 
the  family,  and  in  sixty-eight  instances  it  was  asserted  that 
no  hereditary  strain  could  be  discovered.  According  to  the 
German  Sammelforschung,  in  9%  of  the  males  and  10.3%  of 
the  females  hereditary  predisposition  for  cancer  was  found.^ 
The  experimental  study  of  tumors  has  thus  far  not  furnished 
any  decided  proof  of  the  value  of  heredity  as  a  causal  factor, 
and  Bashford  is  inclined  to  deny  its  influence  altogether.  It 
follows,  —  though  the  figures  are  very  uncertain,  —  that  the 
incidence  of  malignant  growths  of  the  lungs  does  not  appear 
to  be  seriously  affected  by  hereditary  strain. 

The  influence  of  sex.  M.  Askanazy*  maintains  that  there 
is  a  distinct  connection  between  premature  sexual  develop- 
ment and  the  development  of  malignant  growths.  Among 
tumors  of  other  kinds  he  quotes  also  Linser,*  who  reported 
the  case  of  a  boy  thirteen  years  of   age  with  a  complete 

1  Primary  Cancer  of  Lungs,  Nov.  Med.  Arch.,  Stockholm,  1897,  N.  F.  VIII, 
Festband,  Axel  Key;  and  Lubarsch  and  Ostertag,  Ergebnisse,  Wiesbaden,  1904, 
Vol.  VIII,  1902. 

2  Quoted  from  Lewin,  loc.  cit. 

3  t)ber  Sexuelle  Friihreife,  Zeitschr.  f.  Krebsforsch.,  Vol.  X,  Heft.  Ill,  1910. 

4  Virch.  Archiv.,  1899,  Vol.  157,  S.  281. 


22     PRIMARY  MALIGNANT  GROWTHS  OF  THE  LUNG 

development  of  hair  such  as  is  seen  after  development  of 
puberty.  He  died  of  a  tumor  in  the  left  pleural  cavity 
and  mediastinmn  which,  on  examination,  showed  absence  of 
elastic  fibres,  in  stroma,  no  cihated  epitheha,  the  epithehal 
cells  in  certain  places  still  stratified.  The  natural  history  of 
these  evidently  congenital  tumors  is  as  yet  entirely  obscure. 

It  has  always  been  maintained  that  males  are  by  far  more 
frequently  subject  to  lung  tumors  than  females.  Tables  I 
and  II  corroborate  this.  Among  the  374  cases  of  carcinoma 
of  the  limgs,  there  are  269  males,  or  71.9%;  ninety-three 
females,  or  24.8%;  twelve  in  which  the  sex  is  not  stated. 
In  the  same  way,  among  ninety-four  sarcoma  cases,  sixty- 
three,  or  67%,  are  males;  twenty-eight,  or  29.7%,  females; 
three  where  sex  is  not  stated.'  The  domestic  life  led  by 
women,  with  their  consequent  retirement  and  immunity 
from  the  irritations  and  traumatisms  which  must  be  frequent 
in  the  more  unprotected  life  of  men  (the  abuse  of  tobacco  and 
alcohol,  the  many  trades  and  vocations  which  are  accom- 
panied by  irritations  of  the  respiratory  organs,  etc.)  has  been 
adduced  in  explanation  of  this  fact.  The  entire  subject  is 
not  yet  ready  for  final  judgment. 

The  age  of  the  patient.  It  is  indisputable  that  age  has  a 
certain  influence  upon  the  incidence  of  both  carcinoma  and 
sarcoma.  Statistics  seem  to  show  that  carcinoma,  roughly 
speaking,  is  a  disease  of  that  period  of  life  which  follows 
puberty  after  its  completion,  while,  on  the  other  hand,  sar- 
coma as  a  rule  is  a  disease  of  the  earher  years  of  hfe.  But 
there  are  exceptions,  and  no  age  is  entirely  exempt  from 
either  type  of  tumor.  The  following  figures,  gathered 
from  Tables  I  and  II,  clearly  illustrate  this.  It  is  evident 
from  this  that  the  majority  of  carcinoma  cases  hes  beyond 
the  age  of  forty  and  attains  its  maximum  between  the  ages 
of  fifty  and  sixty.  Descending  slowly  there  are  still  two  cases 
remaining  between  eighty  and  ninety,  while  the  majority  of 
sarcoma  cases  lies  below  the  age  of  forty,  cUmbing  up  slowly 
from  the  decade  between  ten  and  twenty,  reaching  the 
maximum  between  thirty  and  forty,  declining  again,  slowly, 
and  there  are  still  five  cases  between  seventy  and  eighty. 


A  FEW  HISTORICAL  NOTES  23 

The  first  decade,  from  birth  to  ten  years,  seems  to  be  kommie 
from  carcinoma  (without  counting,  of  course,  the  few  cases 
of  congenital  tumor). 


Carcinoma 

Sarcoma 

Age  not  stated 

18 

Age  not  stated 

9 

1-10 

0 

1-10 

6 

10-20 

6 

10-20 

12 

20-30 

10 

20-30 

14 

30-40 

30 

30-40 

19 

40-50 

78 

40-50 

14 

50-60 

113 

50-60 

12 

60-70 

94 

60-70 

3 

70-80 

23 

70-80 

5 

80-90 

2 
374 

94 

These  figures  tally  satisfactorily  with  the  age  tables  given 
by  many  authors,  for  instance  Fuchs.^ 

The  question  of  the  influence  of  age  upon  the  incidence  of 
maUgnant  neoplasms  is  one  that  is  intimately  connected 
with  certain  problems  that  have  of  late  years  been  thor- 
oughly studied  and  widely  discussed, — the  problems  of  growth 
and  of  senility  in  their  physiological  and  pathological  bearings. 
The  older  theories,  such  as  those  of  Thiersch  ^  and  others, 
that  as  the  body  grows  older  the  interstitial  tissue  undergoes 
a  change,  the  equilibrium  between  this  and  the  epitheUum 
is  impaired,  in  consequence  of  which  the  epithelial  tissue 
proUferates  and  tends  to  form  carcinoma,  while,  on  the 
other  hand,  in  youth  the  connective  tissue  group  is  apt  to 
overstep  the  bounds  set  to  it  and  thus  sarcoma  and  similar 
tumors  may  be  formed  —  these  theories  no  longer  hold 
good.  It  has  just  been  shown  that  no  age  is  absolutely 
immune  from  the  formation  of  neoplasms  and  that  even  in 
intra-uterine  life  tumors  of  all  kinds  may  be  developed. 
These  facts  seem  to  lead  to  the  unavoidable  conclusion  that 
deeper  and  more  complex  principles  are  involved.  It  is 
altogether  foreign  to  the  purpose  of  this  study,  and  would 
require  a  book  by  itseK,  to  go  into  details  concerning  the 
modem  theories  of  growth  and  senility.     It  will  suffice  to  say 

^  Beitrage  zur  Kasuistik  des  prim.  Lungencarzinoms,  Diss.  Leipzig,  1890. 
*  Log.  cit. 


24     PRIMARY  MALIGNANT  GROWTHS  OF  THE  LUNG 

that  developmental  energy  of  a  high  degree  becomes  active 
as  soon  as  the  sperma  enters  the  ovum.  After  that,  until 
the  organism  is  fully  grown,  there  is  a  continuous  balancing 
of  energies  as  manifested  in  highly  compHcated  chemical 
and  physical  processes.  Immediately  with  the  completion 
of  growth,  the  changes  begin  which  lead  to  senescence  and 
final  destruction  of  the  body.  The  study  of  the  intricate 
chemistry  and  physics  of  growth,  regeneration,  and  senes- 
cence is  by  no  means  concluded,  but  has  in  reaUty  only  just 
begun.  The  relation  of  these  problems  to  the  formation 
and  development  of  neoplasms  is  as  yet  sufficiently  obscure, 
but  many  a  single  ray  of  light  shed  here  and  there  justifies  the 
hope  of  further  enlightenment  in  the  near  future. 

It  is  of  special  interest  in  this  connection  to  study  the  work 
of  Rossle,'^  from  which  only  a  few  conclusions  may  be  quoted. 
It  appears  to  him  as  certain  that  hypersemia  is  able  to 
produce  a  considerable  increase  in  the  number  of  those  cells 
which  are  organically  an  integral  part  of  the  matrix,  and 
for  that  reason  are  subject  to  the  laws  of  nutrition  specific 
to  the  latter.  Hypersemia,  however,  cannot  produce  those 
biological  alterations  in  the  cells  in  consequence  of  which 
endless  proliferation  is  caused.  Rossle  agrees,  also,  that 
hypersemia  alone  cannot  account  for  the  development  of 
tumor,  but  must  be  associated  with  many  other  factors, 
among  others,  probably  senescence.  His  aphorisms  con- 
cerning senility  are  also  most  plausible  and  interesting.  There 
may  be  senescence  of  the  entire  organism  or  of  individual 
organs  only.  SeniHty  does  not  attack  different  parts  of  the 
body  simultaneously.  While  one  part  may  long  ago  have 
become  senescent,  other  organs  may  as  yet  be  quite  youthful. 
According  to  Rossle,  the  general  law  may  probably  be  that 
the  more  intense  the  function,  the  sooner  the  cell  grows  old. 
It  is  doubtful  if,  with  all  their  plausibihty,  these  theories  will 
stand  before  more  than  a  superficial  investigation.  Rossle 
further  asserts  that  epithelium  in  general  retains  its  juvenile 
status  approximately  during  the  entire  life  of  the  individual 

1  Die  RoUe  der  Hyperamie  und  des  Alters  in  der  Geschwulstentstehung, 
Munch.  Med.  Woch.,  1904,  p.  1330. 


A  FEW  HISTORICAL  NOTES  25 

and  can  be  rejuvenated  by  karyokinesis  and  regeneration. 
The  earlier  in  the  course  of  the  life  of  an  organism  a  tissue 
becomes  senile  the  earher  it  will  be  possible  for  tumors  to 
be  developed  from  this  tissue,  for  according  to  Rossle  it 
is  not  those  cells  and  tissues  which  have  become  senile, 
but  those  which  have  remained  youthful  and  capable  of 
reproduction  and  regeneration,  which  form  the  origins  of 
these  tumors. 


CHAPTER  IV 

PRECANCEROUS  INFLUENCES  {Continued) 

AS  all  these  questions  are  most  intimately  connected  with 
the  question  of  the  etiology  of  tumors,  it  will  be  best 
to  say  a  few  words  in  this  place  on  the  subject  of  etiology,  at 
present  the  centre  of  so  much  discussion  and  labor.  The 
despairing  exclamation  of  Heyf elder,  ^  —  "Je  passe  sous 
silence  Fetiologie  et  le  traitement  de  cette  maladie  qui, 
jusqu'a  present,  est  hors  du  domaine  de  Tart,"  —  is  for- 
tunately no  longer  true  in  its  entirety.  But  still  it  must  be 
confessed  that,  with  all  the  colossal  labor  expended  on  the 
question  of  the  etiology  of  tumors  in  the  last  half-century,  the 
fundamental  cause,  the  unknown  X,  that  lies  at  the  very 
bottom  of  all  these  manifold  processes,  is  still  entirely  obscure 
and  there  is  as  yet  not  even  a  sufficient  basis  for  an  intelhgent 
statement  of  the  question  that  would  seem  to  promise  any 
result.  What  we  know  to-day  of  the  physiology,  the  chemis- 
try, and  physics  of  growth  and  senihty  seems  to  suggest  that 
mahgnant  neoplasms  might  in  general  be  accounted  for  in 
either  one  of  two  ways,  and  the  discussions  as  to  etiology 
actually  do  gravitate  about  these  two  points.  Firstly,  one 
might  suppose,  seeing  that  the  greatest  energy  and  the 
foundations  for  its  proper  balance  are  put  out  in  early  foetal 
life,  that  neoplasms  are  based  ultimately  on  some  earUer  or 
later  intra-uterine  disturbance.  This  is,  indeed,  the  theory 
that  was  furnished  and  elaborated  by  Cohnheim  and  his 
followers. 2     Cohnheim,  however,  did  not  look  upon  all  this 

^  Du  Cancer  du  Poumon,  Arch.  Gen.  de  Med.,  Vol.  14,  2d  Series,  1837, 
p.  345. 

^  Many  years  before  Cohnheim,  in  the  paper  by  Langstaff  (Table  II,  No. 
49)  in  1818,  that  author  says  ^p.  345)  that  he  has  noticed  "pulpy  tumors  in  the 
lungs  of  adult  persons  who  had  not  been  affected  during  their  lives  with  the 
least  symptoms  of  pulmonic  disorder  and  who  died  of  active  disease  of  a 

26 


PRECANCEROUS  INFLUENCES    (Continued)  27 

from  the  mere  standpoint  of  general  physiology  and  of  chem- 
istry, but  assmned  remnants  of  embryonal  tissue  in  this 
or  that  organ  which,  left  over,  as  it  were,  and  endowed 
with  proliferative  energy,  might  under  favorable  conditions 
become  active  and  produce  tumors. 

This  theory  of  Cohnheim,  which,  for  reasons  not  necessary 
to  state  here,  seemed  untenable,  was  again  revived,  though 
in  a  much  modified  form,  by  Borst  ^  and  his  followers.  Borst 
assumed,  as  the  necessary  foundation  for  the  formation  of  neo- 
plasms, early  disturbances  in  the  intra-uterine  development, 
the  nature  of  which  is  not  as  yet  accurately  known.  Accord- 
ing to  him,  it  is  not  necessary  to  assume  the  bodily  presence 
of  actual  embryonal  remnants.  He  remarks  that,  according 
to  his  view,  it  is  highly  probable  that  each  organ  has  its  own 
peculiar  onkology.  A  true  carcinoma  is  not  developed  out  of 
any,  no  matter  how  irregular,  form  of  inflammation,  no  trans- 
formation into  carcinoma  is  effected  when  short,  glandular, 
cuboid  cells  happen  to  be  turned  into  high  cylindrical  cells 
of  entirely  different  structure  or  when  high  cylindrical 
cells  happen  to  be  changed  into  others,  again  of  different 
structure  and  of  different  function,  or  when  single  layers  of 
pavement  epithelium  become  stratified  into  numerous  layers 
of  epidermal  cells.  All  these  and  many  more  deformations  of 
epithelium  might  be  mentioned  which,  according  to  Borst's 
view,  would  in  no  wise  transform  the  particular  growth 
in  hand  into  a  carcinoma.  What  Borst  does  require,  and 
requires  without  exception,  is  just  that  transformation  of  an 
epithelial  cell  into  one  of  cancerous  character,  on  the  details 
of  which  so  many  express  differing  opinions,  and  the  character 
of  which  is  so  difficult  to  describe  and  yet  is  so  readily  accepted 
as  a  matter  of  belief. 

different  description  in  other  viscera."  He  is  inclined  to  think  that  fungus 
haematodes  and  cancer  and  scrofula  "have  their  origin  perhaps  with  the 
formation  and  development  of  the  natural  parts  of  the  foetus  in  utero  and 
that  they  remain,  after  the  birth  of  the  individual,  in  some  instances  dormant 
or  inactive  for  a  series  of  years,  and  in  all  only  require  a  peciiliar  morbid 
excitement  to  occasion  this  increase  and  destructiveness." 

^  Die  Lehre  von  den  Geschwlilsten,  Wiesbaden,  1902.  Uber  atypische 
Epithelwucherung  und  Krebs,  Verhand.  Deutsch.  Path.  Ges.,  Vol.  6-7,  1903- 
1904,  p.  110. 


28     PRIAIARY  MALIGNANT  GROWTHS  OF  THE  LUNG 

It  would  be  most  interesting  to  continue  in  detail  the 
history  of  the  various  theories  and  speculations  which  have 
led  to  the  present  state  of  our  knowledge  of  mahgnant 
tumors.  This  is  impossible,  because  the  subject  of  this 
essay  is  tumors  of  the  lung,  and  not  mahgnant  growths  in 
general.  The  necessity  of  closely  adhering  to  this  special 
subject  is  still  more  imperative  because  of  the  enormous 
material  on  tumors  in  general  pubhshed  from  year  to  year, 
a  few  examples  of  which  have  abeady  been  mentioned,  as 
Willams,^  Borst,^  the  various  writings  of  Ribbert  and  espe- 
cially his  latest.^  But  even  a  simple  catalogue  of  the  more 
important  writings  on  these  subjects,  with  only  carcinoma 
as  a  subject,  would  be  enough  to  fill  a  small  book.  Does  it 
not  after  all  seem  as  if  one  theory  were  as  good  as  another 
and  might,  by  some  clever  reasoning,  be  selected  according 
to  the  subjective  taste  of  the  author  who  elects  to  defend  it? 
In  the  writer's  opinion,  the  best  evidence  appears  to  be  on  the 
side  of  Borst  and  his  followers.  Be  that  as  it  may,  one  can 
only  reiterate  again  and  again  that,  with  all  the  labor  and  time 
spent  on  these  questions  by  workers  in  many  separate  fields 
of  research,  and  especially  the  tremendous  amount  of  experi- 
mental work  that  has  of  late  years  been  done  by  Ehrlich 
and  his  school,  by  Bashf  ord  and  many  others,  —  while  it  has 
added  much  that  is  valuable  to  our  general  knowledge  and 
has  been  of  immense  service  to  our  better  understanding  of 
many  medical  and  biological  problems,  especially  of  onkology, 
—  in  spite  of  all  this,  no  light  has  been  shed  upon  the  ultimate 
etiology  of  tumors,  and  the  words  of  Kraske  ^  are  in  the  main 
still  true,  —  ''We  know  no  more  to-day  of  cancer  than  did  our 
grandfathers." 

That  cases  of  tuberculosis  the  world  over,  thanks  to  the 
preventive  work  done  everywhere,  are  steadily  diminishing 
in  number  seems  indubitable.  There  is,  as  we  have  seen,  a 
great  deal  of  legitimate  doubt  as  to  the  increase  of  carcino- 
sis.   Behla  ^  has  pointed  out  that  by  adequate  disinfection  of 

^  Loc.  cit.  ^  Loc.  cit. 

^  Das  Karzinom  des  Menschen,  etc.,  Hugo  Ribbert,  Bonn,  1911. 

«  Naturforschen^ersammlung  in  Freiburg,  Marz,  1902. 

^  Loc.  cit.,  p.  177. 


PRECANCEROUS  INFLUENCES    (Continued)  29 

tubercular  sputum,  ulcers,  and  numerous  other  places  where 
tubercle  baciUi  may  be  found  or  suspected,  by  proper 
isolation  and  proper  sanitaria,  etc.,  the  progress  of  tuber- 
culosis can  to  some  extent  be  arrested  and  that  a  much 
greater  advance  in  the  arresting  of  this  scourge  of  mankind 
may  be  hoped  for  in  the  future.  It  is  quite  different  with 
carcinoma.  There  is  as  yet  no  known  primary  cause  for 
malignant  growths.  Among  the  multitude  of  contagions 
that  we  know  at  the  present  day,  none  has  been  found  that 
seems  to  have  any  connection,  causative  or  otherwise,  with 
carcinoma  or  sarcoma.  Carcinomatosis,  therefore,  does  not 
show  any  similarity  with  the  contagious  character  of  tuber- 
culosis. It  does  not  seem  to  spread  infection  from  individual 
to  individual.  It  is  more  than  doubtful  whether  environment, 
as  some  authors  maintain,  plays  any  active  part  in  the 
development  of  mahgnant  growths.  Behla  has  not  suc- 
ceeded in  proving  that  special  forms  of  vocation,  trade, 
occupation,  etc.,  or  calling  of  any  kind,  have  any  active 
part  in  the  causation  of  lung  tumors.  It  is  true  enough 
that  certain  kinds  of  work  are  apt  to  produce  inflammatory 
conditions  (bronchitis  acute  or  chronic,  anthracosis,  siderosis, 
chronic  indurative  pneumonia,  and  others),  and  the  locaU- 
zation  of  tuberculosis  may  possibly  be  determined  by  such 
factors.  But  it  has  never  been  proven  that  any  increased 
tendency  toward  the  development  of  mahgnant  tumors  is 
caused  thereby.^ 

It  may  be  convenient  in  this  connection  to  refer  briefly  to 
the  so-called  cancer  of  the  lungs  as  occurring  in  the  mines  of 
Schneeberg,  Silesia,  Germany.^  It  was  thought  that  here  at 
least  was  proof  positive  of  the  production  of  mahgnant  growths 
solely  by  the  injurious  effects  of  purely  exogenic  influences 
as  furnished  by  irritating  occupations.     In  this  small  Silesian 

^  Conf.  the  work  of  Williams,  loc.  cit.;  Karl  Kolb,  Der  Einfluss  des  Berufes 
auf  die  Haufigkeit  des  Krebses,  Zeitschr.  f.  Krebsforsch.,  Vol.  IX,  Heft  III, 
Berlin,  1910;   Behla,  loc.  cit.,  and  many  others. 

2  Hesse,  Das  Vorkommen  von  primarem  Lungenkrebs,  die  Bergkrankheit 
in  den  Schneeberger  Gruben.  Vierteljahrschrift  f.  gerichtliche  Medizin,  1879, 
pp.  296  ff.  Also  Ancke,  Lungenkrebs  der  Schneeberger  Erzarbeiter,  Diss. 
Miinchen,  1884.     Also  Komer,  Munch.  Med.  Woch,,  1888,  No.  11. 


30     PRIMARY  MALIGNANT  GROWTHS  OF  THE  LUNG 

town  there  were  eight  mines  extending  to  a  depth  of  fifteen 
hundred  yards,  from  which  cobalt,  nickel,  and  bismuth 
were  obtained.  There  were  from  six  to  seven  hundred  men 
employed  in  the  mines,  and  of  these  the  yearly  mortaUty, 
excluding  accidents  and  the  like,  was  about  twenty-eight  to 
thirty-two,  of  which  twenty-one  to  twenty-four  were  from 
carcinoma  of  the  lungs,  so  that  a  total  of  seventy-five  per 
cent  of  all  miners  in  this  town  died  from  this  disease.  The 
worker  was  never  affected  until  after  twenty  years  of  mine 
work,  usually  later,  while  the  worker  who  siurvived  fifty 
years  of  mine  work  was  generally  immune.  Heredity  can  be 
excluded,  for  only  those  who  worked  in  the  mines,  and  worked 
steadily,  were  afflicted.  Those  who  did  not  work  continu- 
ously in  the  mines,  or  who  had  other  occupations  besides 
mining,  or  who  lived  better  on  the  whole,  might  live  to  be 
seventy  years  or  over.  The  symptoms  need  not  be  described 
here.  The  autopsies  showed  that  the  disease  always  com- 
menced from  the  root  of  the  lung  where  the  lymph  nodes 
were  involved  and  enlarged,  ranging  from  the  size  of  a  walnut 
to  that  of  a  fist.  Sometimes  secondary  tumors  in  the  subcutis 
of  the  thorax,  visible  from  without,  occurred.  The  timiors 
were  examined  frequently,  especially  by  E.  Wagner,^  who 
found  the  nodules  to  be  true  Ijmapho-sarcoma.  Cohnheim  ^ 
had  already  hinted  at  the  likelihood  of  these  tumors  not  being 
real  tumors  at  all,  but  products  of  some  infection.  The  ques- 
tion was  studied  in  all  directions.  It  was  found  that  only 
those  who  did  actual  mining,  and  for  a  considerable  number  of 
years,  were  attacked  by  the  malady;  that  there  was  no  local 
irritation  caused  by  the  nickel  or  cobalt  or  bismuth  particles, 
but  that  it  was  a  form  of  poisoning  due  to  the  arsenic  found 
in  some  quantity  in  those  ores.  In  other  mines  of  cobalt, 
nickel,  etc.,  in  Sweden,  Hungary,  and  the  Tyrol,  where  the 
ore  contained  no  arsenic,  the  disease  did  not  occur.  Since 
the  authorities  have  sufficiently  ventilated  the  mines  and 
have  properly  regulated  the  lives  of  the  miners,  nothing  has 
been  heard  of  the  ^'Schneeberger  Lungenkrebs." 

^  Eulenberg's  Vierteljahrschr.  f.  Gerichtl.  Medizin. 
2  Vorlesungen,  Vol.  I»  p.  718. 


PRECANCEROUS  INFLUENCES    (Continued)  31 

Trauma.  Much  stress  has  been  laid  on  traumatism  as  an 
important  factor  in  the  development  of  malignant  neoplasms. 
By  "traumatism"  is  meant  here  the  injuries  of  the  grosser 
kind,  like  severe  contusions  by  blows,  falls,  and  similar 
occurrences.  It  is  always  claimed  that  these  severer  forms 
of  traumatism  have  some  intimate  and  direct  relations  with 
the  development  and  growth  of  maUgnant  tumors;  in  fact 
are  the  growth-determining  element.  Statistics,  however, 
do  not  seem  to  bear  this  out.  Among  the  material  col- 
lected in  Table  I  dealing  with  carcinoma,  there  are  but  six 
cases  in  which  traumatism  in  the  ordinary  larger  sense  is 
recorded.^ 

The  really  effective  action  of  traumatism  has  for  a  long 
time  been  considered,  as  displayed  in  the  development  of 
sarcoma.  Among  the  ninety  cases  tabulated  on  Table  II, 
there  are  only  two  cases  (Nos.  15  and  51)  in  which  trauma  is 
recorded.  This  seems  to  eliminate  once  and  for  all  the  idea 
that  traimiatism  of  the  grosser  kind,  at  least,  has  any  part  in 
the  development  either  of  sarcoma  or  of  carcinoma.  Granted 
that  the  figures  are  very  uncertain  and  clinical  history  and 
careful  observations  lacking,  the  small  percentage  of  cases  in 
which  trauma  is  associated  with  the  formation  of  tumors  can 
only  be  due  to  a  coincidence.  It  might,  of  course,  be  claimed 
that  the  tumor,  —  carcinoma  or  sarcoma,  —  had  been  latent 
before  trauma,  and  that  the  trauma  merely  hastened  the 
growth  of  the  tumor.  This  is  capable  neither  of  proof  nor  of 
disproof  and  must  remain  for  the  present  a  matter  of  beUef 
and  not  of  knowledge.  Experimentally,  so  far  as  can  be  seen, 
convincing  testimony  has  not  been  brought  forward  in  either 
direction,  but,  as  we  must  constantly  keep  in  mind,  no 
experimentation  of  any  kind  has  as  yet  been  able  to  produce 
an  experimental  case  of  malignant  growth.  The  question 
of  traumatism  is,  of  coiu-se,  still  much  discussed  and  it  is 
surprising  to  note  the  lengths  to  which  some  authors  are 
prepared  to  go.  Herzfeld,^  for  instance,  concludes  his  work 
with  the  sentence,  ^'Ohne  Trauma,  kein  Tumor"  (No  tumor 

1  Nos.  81,  104,  115,  158,  161,  and  177. 

'  Tumor  and  Trauma,  Zeitschr.  f .  Krebsforsch.,  Vol.  3,  1905,  p.  73. 


32     PRIMARY  MALIGNANT  GROWTHS  OF  THE  LUNG 

without  trauma).  One  interesting  case  is  reported  by 
Schoppler/  in  which  a  fall  down  stairs  with  severe  contusion 
of  the  left  mamma  was  supposed  to  have  given  rise  to  a 
carcinoma,  that  portion  of  the  breast  having  been,  supposedly, 
healthy  before  trauma.  It  was  quickly  operated  and  the 
diagnosis  corroborated  by  the  microscope.  The  author 
considers  this  a  convincing  proof  of  the  development  of  a 
carcinoma  from  a  single  traumatism.  The  writer  does  not 
think  that  he  has  proved  his  case,  since,  in  order  to  have 
absolute  proof,  it  would  be  necessary  to  have  demonstrated, 
microscopically  and  otherwise,  before  the  fall,  that  the 
portion  of  the  breast  affected  had  been  entirely  healthy. 
One  must  coincide  with  Bostrom^  in  so  far  as  he,  with 
other  authors,  claims  that  no  malignant  tumor  can  be  de- 
veloped after  a  single  traumatism,  from  tissue  previously 
healthy.  It  is  not  possible,  however,  to  accept  uncondi- 
tionally his  further  statements,  that  these  large  traumatisms 
may  act  as  coincidental  irritants  and  causes  of  mahgnant 
growths. 

Besides  these  blows  and  contusions,  falls  and  all  the  grosser 
forms  of  traimiatisms,  those  smaller  irritations  which  lead  to 
chronic  infianmiations  and  indurations,  to  hyperplasia,  and 
often  to  hj^ersecretion  and  hyposecretion  of  the  tissues,  must 
be  considered  under  the  general  head  of  traumatism.  On 
this  subject  there  is  also  a  very  large  literature  which  cannot 
be  mentioned  here.  A  part  of  it  will  be  found  in  Schoppler.' 
Besides  the  usual  standard  works,  there  are  also  the  publica- 
tions of  Brosch,^  Schuchhardt,^  and  Ropke.^ 

Chronic  irritations  affecting  the  respiratory  organs  are 
numerous  and  are  supposed  by  many  to  play  a  very  active 

iZeitschr.  f.  Krebsforsch.,  Vol.  10,  No.  2,  1911,  p.  219.  Einmaliges 
Trauma  und  Carcinom. 

2  Traumaticismus  und  Parasitismus  als  Ursachen  der  Geschwiilste,  Giessen, 
1902.  » Loc.  cit. 

*  Theoretische  und  experimentelle  Untersuchungen  zur  Pathogenese  u. 
Histogenese  der  malignen  Geschwiilste.     Quoted  after  Wolff,  loc.  cit. 

*  Beitrage  z,  Entstehung  des  Carcinoms  aus  chronischentzundlichen  Zu- 
standen  der  Hautdecken  und  Schleimhaute,  Volkmanns  Samml.  klin.  Vortr., 
No.  257,  1885. 

6  Arch,  f .  Klin.  Chirurgie,  Bd.  78,  1905,  H.  II. 


PRECANCEROUS  INFLUENCES    (Continued)  33 

part  in  the  causation  of  tumors  of  the  lung.  Such  causes 
are  supposed  to  account  for  the  predominance  of  males  over 
females  in  the  occurrence  of  tumors.^  It  is  very  generally 
stated  that  the  right  side  is  the  favorite  localization  of  car- 
cinoma of  the  lung,  and  this  is  supposed  to  be  in  consequence 
of  the  anatomical  and  physiological  conditions.  The  right 
bronchus  is  shorter  and  wider  than  the  left,  its  course  is 
considerably  straighter,  and  it  seems  natural  enough  that 
irritating  substances,  both  chemical  and  mechanical,  are 
aspirated  more  easily  into  the  right  than  into  the  left 
bronchus.  The  following  figures  calculated  from  Tables  I 
and  II  seem  to  show  that  for  carcinoma  there  is  a  pre- 
dominance in  favor  of  the  right  side  amounting  to  thirty- 
one  cases.  For  sarcoma,  on  the  other  hand,  there  seems 
to  be  a  predominance  in  favor  of  the  left  side.  The  figures 
calculated  from  Table  III  show  no  predominance  of  either 
side. 

Carcinoma  Sarcoma 

Right  side      188  Right  side      36 

left  157  left  51 

both  18  both  2 

doubtful  3  not  stated        5 

not  stated  8  94 

374 

Comparison  of  these  figures  shows  results  so  inconstant  and 
differences  so  slight  that  it  would  not  be  wise  to  build  any 
theories  thereon.  A.  FrankeP  comes  to  a  similar  conclusion, 
though  based  on  a  much  smaller  material. 

Tuberculosis.  The  authority  of  Rokitansky  for  a  long 
time  sustained  the  dogma  that  carcinoma  and  tuberculosis  are 
incompatible  diseases;  in  other  words,  that  where  tubercu- 
losis is  found  a  cancer  cannot  develop.  Another  view,  at 
one  time  popular,  is  expressed  by  an  aphorism  of  Crazet^ — 
"The  cancerous  easily  become  tuberculous,  but  the  tuber- 
culous do  not  easily  become  subject  to  cancer."    Actual 

1  Conf.  p.  22,  Chap.  III.  "  Loc.  cit. 

3  Coincidence  et  rapport  du  tuberculose  avec  le  cancer,  These  de  Paris, 

1878. 

4 


34     PRIMARY  MALIGNANT  GROWTHS  OF  THE  LUNG 

experience  has  since  shown,  not  only  that  carcinoma,  espe- 
cially of  the  cancroid  variety,  is  sometimes  found  in  a  tuber- 
culous cavity,  but  that  ordinary  pulmonary  tuberculosis,  with 
breaking  down  of  tissue  and  formation  of  cavities,  as  well 
as  miUary  tuberculosis  and  locahzed  tuberculosis  in  other 
organs,  may  be  associated  with  pulmonary  neoplasms.  In 
some  cases  the  diagnosis  of  associated  pulmonary  neoplasm 
and  tuberculosis  has  been  made  during  life.  A  selection  of 
cases  taken  from  the  collected  material  will  serve  to  illustrate 
the  association  of  mahgnant  growths  and  tuberculosis. 
Tumor  was  present  in  every  case,  whether  expressly  men- 
tioned or  not. 

Table  I 


54  Cohn 

Autopsy 

Tuberculous  cicatrix  in  right  apex  and  in  Bau- 
hini's  valve 

87  Friedlander 

Autopsy 

Cancer  in  left  bronchus  and  tuberculous  cavity 
left  lung 

98  Gougerot 

Clinical 

Pulmonary  tuberculosis  of  old  standing 

106  Harbitz 

Clinical 

Tuberculous  family  history 

257  Perrone 

Sputum 

No  tubercle  bacilli 

Autopsy 

Tubercular  cavity  at  left  apex,  wall  of  cavity 
penetrated  by  tumor 

295  Sehrt 

Autopsy 

Carcinoma  right  bronchus,  extensive  ulcerative 
tuberculosis 

343  Wolf 

Clinical 

Chronic  phthisis 

Autopsy 

Tubercular  cavity  left  lung  and  tumor 

344  WoK 

Clinical 

Chronic  phthisis 

Autopsy 

Tubercular  cavity  right  lobe  and  tumor 

346  WoK 

Clinical 

Signs  of  pulmonary  phthisis 

Autopsy 

Tumor  left  apex,  mihary  tubercles  over  right 
pleura 

348  Wolf 

Autopsy 

Tumor  of  right  upper  lobe  surrounded  by  fresh 
miUary  tubercles,  both  suprarenals  tubercu- 
lous, tuberculous  ulcer  in  ileum 

349  Wolf 

Autopsy 

Nodules  root  of  right  lung,   excrescences  on 
membrane  of  larger  bronchi,  bifurcation  sur- 
rounded by  large  tumor,  fresh  miUary  tuber- 
culosis of  both  lungs 

350  Wolf 

Autopsy 

Tuberculous  lobe,  tuberculous  pleuritis 

356  Wolf 

Autopsy 

Carcinoma  of  main  bronchus,  miliary  tubercles 
in  liver 

359  Wolf 

Clinical 

Anorexia  and  emaciation  followed  by  signs  of 
right  pulmonary  phthisis 

365  Wolf 

Clinical 

Pulmonary  phthisis 

373  Wolf 

Clinical 

Symptoms  of  tuberculosis  with  bacilli 

Autopsy 

Lesions  of  old  and  more  recent  phthisis 

374  Wolf 

Clinical 

Diagnosis  first  as  tuberculosis,  then  as  ss^jhilis 

PRECANCEROUS  INFLUENCES    (Continued)  35 

Table  II 

36     Hildebrand  Tubercle  bacilli  in  sputum 

79     Schnick  Tubercle  bacilli  in  sputum 

The  cases  will  probably  be  much  more  nmnerous  m 
future,  m  proportion  to  the  increasing  attention  given  to 
this  subject  at  autopsies  and  microscopic  examinations. 
Some  authors  appear  to  take  a  somewhat  extreme  stand 
regarding  the  relation  between  tuberculosis  and  tumors 
generally,  and  of  tumors  of  the  limg  especially.  For  in- 
stance, Aronson  ^  cites  twenty-two  cases  of  his  own  practice 
in  which  tuberculous  patients  had  one  parent  or  both  suffer- 
ing from  carcinoma.  He  even  goes  so  far  as  to  suggest  the 
possibility  that  the  tubercle  bacillus  under  favorable  con- 
ditions might  produce  carcinoma,  and  refers  to  the  lupus 
carcinoma  as  the  connecting  link  between  tuberculosis  and 
carcinoma.  It  is  sufficient  to  quote  the  following  sentence: 
''The  phthisical  diathesis  is  not  only  inherited  from  parents 
suffering  from  tubercular  phthisis,  but  also  from  those  suffer- 
ing from  carcinoma.  Etiologically  considered,  carcinoma, 
lupus,  tuberculosis,  all  these  belong  most  probably  to  a 
single  family."  As  a  counterpart  to  these  exaggerated 
statements,  Bayha^  describes  the  so-called  lupus  epithelioma 
and  declares  this  form  of  epithelial  proliferation  in  no  wise 
cancerous  or  malignant.  He  shows  that  genuine  carcinoma 
develops  much  oftener  on  active  and  fresh  lupus  than  on 
lupus  scars.  The  proclivity  of  carcinoma  to  develop  from 
lupus,  and  especially  from  lupus  scars,  has  been  mentioned  so 
often  as  a  fact  beyond  dispute  that  it  is  important  to  note 
the  results  of  Bayha's  investigation.  He  says  distinctly  that 
there  is  no  direct  transition  from  lupus  to  carcinoma,  but  that 
the  malignant  epithelium  prohferates  into  the  interpapillary 
depressions.  WilUams  ^  reiterates  his  view  that  as  tubercu- 
losis declines,  carcinoma  necessarily  increases.  It  is  also  his 
belief  that  the  systemic  depreciation  that  follows  as  a  conse- 

1  Beziehungen  zwischen  Tuberculose  und  Krebs,  Deut.  Med.  Woch.,  1902, 
No.  37,  p.  842. 

^  Uber  Lupus  Carcinom,  Bruns,  Beitrage  zur  Klin.  Chir.,  Vol.  Ill,  1888, 
p.  1.  »  Loo.  cit.,  pp.  337  ff. 


36     PRIMARY  MALIGNANT  GROWTHS  OF  THE  LUNG 

quence  of  fresh  tuberculosis,  and  even  of  tuberculosis  only 
recently  healed,  is  an  undoubted  factor  in  the  etiology  of 
cancer.  On  the  other  hand,  he  readily  agrees  to  the  fact  that 
while  a  considerable  amount  of  old,  healed,  calcified  tuber- 
culous products  may  be  found  associated  with  neoplasm  in 
the  lungs,  this  association  has  no  further  meaning  than  that, 
cicatrized  tuberculosis  being  so  extremely  common,  the  ordi- 
nary percentage  is  also  found  in  the  cancerous.  Furthermore, 
F.  P.  Weber  and  many  others  suggest  that  old,  quiescent 
tuberculous  foci,  not  yet  completely  cicatrized,  may  be  again 
started  into  activity  by  the  local  as  well  as  systemic  effect 
of  the  cancer,  which  naturally  tends  in  a  great  measure  to 
lower  the  patient's  vitality.  This,  however,  is  a  speculation 
of  which  we  know  nothing. 

The  subject  of  tuberculosis  in  its  relations  to  carcinoma 
should  not  be  closed  without  mentioning  the  theories  of 
Kurt  Wolf."^  Wolf  distinguishes  closely  between  bronchial 
carcinoma  and  carcinoma  of  the  lung  proper.  Of  the  latter 
he  reports  nine  cases,  of  carcinoma  of  the  bronchus  twenty- 
two.  ^  He  points  out  that  bronchial  carcinomata  are  nearly 
always  found  in  those  places  which  are  most  subjected  to 
slight,  but  chronic,  irritations,  especially  on  the  right  side 
and  more  particularly  near  the  bifurcations.  He  does  not  so 
much  refer  to  the  tracheal  bifurcation,  but  more  to  the  bifur- 
cations of  the  second,  third,  fourth,  and  following  orders. 
NatiKally,  all  the  irritations  of  aspiration,  of  dust,  tobacco, 
and  so  on,  as  well  as  coughs,  are  apt  to  centre  about  these 
points.  It  is  there  that  Wolf  most  frequently  finds  very  small 
melanotic  lymph  nodes  which,  even  at  a  very  early  stage, 
are  tuberculous.  Sooner  or  later  a  minute  perforation  into 
the  bronchus  takes  place,  into  which  the  melanotic  contents 
of  the  Uttle  node  are  discharged  ("Pigmentdurchbruch"). 
The  lymph  nodes  on  the  down  track  toward  the  hilus  of 
the  lung,  and  of  the  hilus  itself,  become  enlarged  in  the 
course  of  the  process.  It  is  Wolf's  contention  that  these 
little  melanotic  lymph  nodes  are  apt  to  be  tuberculous;  that 

1  Wolf,  Der  Primare  Lungenkrebs,  Fort.  d.  Med.,  1893,  Vol.  13,  Nos.  18 
and  19.  2  Conf .  Table  I. 


PRECANCEROUS  INFLUENCES    (Continued)  37 

when  penetrating  into  the  bronchus  or  developing  at  the 
root  of  the  lung  they  act  as  a  chronic  irritant  at  the  locali- 
zations most  exposed.  This  "Pigmentdurchbruch,"i  Wolf 
claims,  is  sufficient,  in  persons  hereditarily  predisposed,  to 
start  the  development  of  malignant  growth.  This  malignant 
neoplasm  then  proliferates  in  the  bronchus  first  affected, 
travels  along  the  ramifications  of  the  bronchial  tree,  pene- 
trates into  the  lungs,  and  forms  more  or  less  extensive  timiors. 
This  theory  of  Wolf  has  been  the  subject  of  some  discussion, 
but  has  not  been  generally  adopted.  The  presence  of  the 
tubercle  bacillus  or  any  active  tuberculous  process  has  never 
been  definitely  demonstrated  in  these  minute  lymph  nodes 
or  their  further  development.  He  finds,  out  of  the  thirty- 
one  cases  which  he  reports,  eleven  cases  which  exhibit,  not 
cicatrized  and  inactive,  but  mostly  fresh  and  active  tuber- 
culous processes,  by  the  side  of  indubitable  primary  malig- 
nant neoplasms  in  the  lungs.  This,  however,  does  not  suffice 
to  prove  his  ingenious  theory. 

That  carcinoma  does  occur  on  various  cicatrizations, 
especially  of  the  skin  or  mucous  membrane,  is  a  fact.  It  is 
only  necessary  to  refer  to  the  carcinoma  on  lupus,  previously 
mentioned  in  this  connection,  on  ulcer  of  the  stomach,  on 
leukoplakia,  gall  bladder,  etc.  This  form  of  precancerous 
affection  evidently  is  not  concerned  in  limg  tumors,  unless  we 
except  the  theories  of  Wolf,  just  briefly  outhned,  or  of  some 
other  authors,  who  find  in  tuberculous  cicatrizations  or 
tuberculous  ulcers  a  formative  irritant  for  the  development 
of  carcinoma. 

An  attempt  has  been  made  to  obtain  some  knowledge  of  the 
duration  of  carcinomatous  disease  from  Table  I.  Reliable 
values  are,  however,  not  easily  obtainable,  and  it  is  possible 
to  give  only  an  approximate  and  very  defective  notion  of  the 
duration  of  primary  carcinoma  of  the  lung.  The  reasons  for 
this  are  obvious.  Many  authors  neglect  to  give  any  data 
from  which  the  duration  might  be  deduced,  and  the  patients 
themselves  are  often  so  little  self-observant  and  so  careless 

>  This  "Pigmentdurchbruch,"  so  fax  as  the  writer  knows,  has  been  demon- 
strated only  a  single  time. 


38     PRIMARY  MALIGNANT  GROWTHS  OF  THE  LUNG 

of  their  physical  condition  that  they  seek  medical  aid  long 
after  the  first  appearance  of  symptoms,  the  date  of  which, 
therefore,  can  no  longer  be  fixed.  Finally,  the  first  appear- 
ance of  symptoms  does  not  necessarily  coincide  with  the 
beginning  of  the  disease.  Among  the  374  cases  tabulated  in 
Table  I,  there  are  no  means  of  calculating  the  duration  in 
230  cases.  The  longest  duration  given  is  five  years,  the 
shortest  two  weeks. ^ 

^  For  details,  see  Appendix  A. 


CHAPTER  V 

PATHOLOGY 

THERE  is  an  old  aphorism  saying  that  those  organs 
most  disposed  to  secondary  tmnors  are  least  disposed 
to  the  formation  of  primary  neoplasms.  The  limgs  are 
undoubtedly  a  favorite  locaUzation  for  secondary  tumors, 
but  primary  neoplasms  are  by  no  means  rare.  All  the  types 
of  tumors  represented  in  the  onkology  of  other  organs  may 
also  be  found  in  the  limgs. 

The  gross  appearance  is  not  uniform  or  characteristic.  It 
differs  according  to  the  peculiarities  in  each  individual  case. 
For  carcinoma  of  the  lungs,  the  older  writers  distinguish 
only  between  encephaloid,  or  what  they  called  medullary, 
cancer  ("  Markschwamm "  and  fungus  hsematodes)  and  the 
infiltrated  form,  the  names  being  given  merely  to  indicate 
external  differences.  Jaccoud  ^  mentions  that  primary  cancer 
of  the  lung  is  nearly  always  of  the  encephaloid  variety  and  is 
seen  either  "en  masse"  or  in  a  more  infiltrated  form.  He 
considers  the  "cancer  en  masse"  as  the  more  frequent.  It  is 
not  easy  to  determine  just  what  kind  of  tumor,  —  sarcoma 
or  carcinoma,  —  Jaccoud  had  before  him.  A  much  greater 
variety  in  gross  appearance  of  this  class  of  tumors  is  now 
recognized. 

One  form  that  occurs  occasionally  is  that  of  a  single 
nodule,  usually  quite  small,  surrounded  perhaps  by  a  few 
minute  miliary  nodules  deeply  buried  in  the  lung  tissue  of  one 
lobe,  producing  only  very  slight  or  possibly  no  symptoms 
during  life,  and  as  a  rule  discovered  by  mere  accident  at 
autopsy.     These  cases  are  rare.    The  writer  has  seen  two. 

There  is  the  so-called  mihary  form  of  carcinosis,  which  in 

^  Jaccoud,  Legons  de  Clinique  m^dicale,  1871-72,  p.  454,  Cancer  de  pou- 
mon;   Traits  de  pathologic  interne,  Vol.  2,  p.  120. 

39 


40     PRIMARY  MALIGNANT  GROWTHS  OF  THE  LUNG 

the  gross  resembles  very  nearly  an  eruption  of  miliary  tuber- 
cles.^ There  is  perhaps  this  difference,  that  the  little  nodules 
are  somewhat  larger  than  the  tubercles  and  have  not  the 
peculiar  grayish  translucent  appearance,  but  are  more  whitish 
and  generally  distributed  along  the  lymphatics.^  The  reader 
is  referred,  for  a  history  and  description  of  the  acute  miliary 
carcinosis  in  general,  to  J.  Wolff. ^  As  for  the  lungs,  there 
seems  to  be  no  doubt  that  a  miUary  carcinosis  actually  exists, 
as  Rokitansky*  and  Elisberg^  hold,  but  it  is  probable  that 
these  cases  are  not  always  primary.  It  is  very  much  more 
likely  that  they  are  secondary  to  some  small  tumor  that — 
possibly  owing  to  lack  of  symptoms,  possibly  because  hidden 
away  in  the  depths  of  some  bulky  organ  —  was  not  detected. 
The  nodular  form  of  primary  carcinoma  of  the  lung  as  a  rule 
involves  in  its  beginnings  only  a  portion  of  one  lung,  while 
metastatic  carcinomatous  nodules  in  the  lungs  are  apt  to  be 
distributed  throughout  both  lungs.  The  nodules  are  found 
of  varying  sizes,  from  that  of  a  cherry  pit  or  walnut  to  that 
of  an  egg,  small  apple,  or  even  a  human  fist.  They  are  not 
usually  confluent,  but  are  separated  from  each  other  by 
lung  tissue.  The  boundary  between  the  tumor  and  the  lung 
is  sharply  defined.  As  the  process  continues,  the  lung  tissue 
intervening  between  nodules  often  becomes  involved  in 
secondary  inflammatory  and  degenerative  conditions,  and  the 
nodules,  as  they  increase  in  size,  may  merge  one  into  the 
other.  Jaccoud,®  and  since  his  time  others,  have  been  of 
opinion  that  cavities  and  breaking  down  of  tissue  within 
these  nodular  carcinomata  do  not  occur,  or  at  all  events 
are  very  rare.  On  the  contrary,  however,  the  material  col- 
lected in  Table  I  will  show  that  the  formation  of  irregular 
cavities,  especially  in  the  larger  nodulated  tumors,  is  a 
common  occurrence.  The  gross  appearance  on  section  of 
these  nodules  varies  according  to  the  kind  of  tumor  and  the 
condition  in  which  it  happens  to  be,  and  it  is  therefore  not 

^This  form  was  first  described  by  Demme,  Schweiz.     Monatschrift  f. 
prakt.  Medizin,  Jahrg.  Ill,  1858,  No.  VI. 

2  Conf.  Wunderlichs  Archiv.,  1857.  '  Table  I,  No.  80. 

»  Loc.  cit..  Vol.  II,  pp.  398  S.  "  Loc.  cit. 

« Loc.  cit.,  1856,  Vol.  I,  p.  255. 


PATHOLOGY  41 

possible  to  present  a  uniform  and  generally  applicable 
description.  One  may  be  sure,  however,  that  besides  the 
usual  grayish-white  or  yellowish  or  pinkish-white  tumor 
material  there  may  be  found  pathologically  altered  bronchi 
and  vessels,  bronchiectatic  dilatations,  and,  as  has  been 
said,  occasional  cavities.  The  cavities  have  ragged,  irregular 
walls,  consisting  of  tumor.  Stumps  of  vessels  and  bronchi 
often  protrude  into  them  from  the  walls.  The  cavities 
usually  contain  detritus  from  tumor  material,  old  or  fresh 
blood,  mucus,  and  so  on. 

The  infiltrating  form.  This  form  is  very  common.  Sepa- 
rate nodules,  large  and  small,  are  rare.  The  tumor,  usually 
starting  from  a  bronchus,  penetrates  the  bronchial  wall  and 
infiltrates  the  lung  along  the  bronchial  as  well  as  the  venous, 
arterial,  lymphatic,  and  even  nerve  ramifications.^  This 
type  is  subject  to  many  variations,  according  as  the  infiltra- 
tion happens  to  proliferate  mainly  along  the  preformed  track 
of  the  bronchial  ramifications  or  extends  down  to  the  root  of 
the  lung,  involving  not  only  larger  bronchi  but  also  the  bron- 
chial, tracheal,  and  mediastinal  glands.  It  thus  forms,  besides 
extensive  pulmonary  infiltrations,  considerable  masses  of 
tumor  at  the  root  which,  in  their  effect  upon  larger  bronchi, 
trachea,  large  vessels,  and  other  mediastinal  organs,  cause 
bronchiectatic  dilatations,  atelectatic  areas,  even  gangrene, 
in  the  lungs,  and  all  those  symptoms,  to  be  discussed  later, 
which  pertain  to  intra- thoracic  growths  in  general.  ^ 

There  is  another  type  of  infiltrating  tumor  affecting  only 
a  portion  of  a  lobe.  This  starts  as  a  rule  from  smaller  bronchi 
or  bronchioli;  the  infiltration  is  sharply  defined  against  the 
normal  lung  tissue,  and  is  so  dense  that  within  the  region 
of  the  tumor  scarcely  any  lung  tissue  can  be  found.  The 
entire  area  is  taken  up  by  tumor  in  which  only  a  few  arteries 
and  veins  and  some  slight  dilated  bronchi  are  visible.' 

In  Plate  2  the  destruction  of  almost  the  entire  lung,  from 
top  to  bottom,  is  well  shown.    There  is  little  healthy  lung 
tissue,  for  nearly  the  entire  lung  is  gone  and  the  pulmo- 
nary tissue  replaced  by  tumor,  at  first  creeping  along  and 
» Stilling,  Table  I,  No.  310.  *  Conf.  Frontispiece.  »  Plate  1. 


42     PRIMARY  MALIGNANT  GROWTHS  OF  THE  LUNG 

infiltrating  the  lung  tissue,  then  degenerating  and  breaking 
down  iato  cavities,  etc.,  as  described. 

The  gross  forms  thus  far  described  apply  in  general  only 
to  carcinoma  of  the  lungs.  The  rare  cases  of  sarcoma 
may  assume  similar  macroscopic  forms  and  it  will  then 
become  difficult  to  distinguish  sarcoma  from  carcinoma  with- 
out the  aid  of  the  microscope.  There  is  one  gross  form, 
however,  that  is,  to  all  intents  and  purposes,  pecuUar  to 
sarcoma.  This  form  appears  as  very  large  tumors  with 
fairly  homogeneous  structure,  sometimes  containing  cavities, 
but  comparatively  rarely,  and  never  when  the  tumor  is  a 
lymphosarcoma.  These  growths  may  become  so  large  as  to 
occupy  the  entire  half,  or  more,  of  the  chest.  That  portion 
of  the  lung  which  is  not  destroyed  and  replaced  by  tumor 
remains  as  a  mere  shell  around  this  growth.  Heart,  dia- 
phragm, mediastinal  contents  may  be  extensively  displaced. 

This  very  brief  and  necessarily  incomplete  sketch  of  the 
mere  gross  appearances  will  suffice  to  show  how  varied  and 
comphcated,  how  difficult  of  interpretation,  are  the  post- 
mortem pictures  presented  by  lung  tumors.  Sometimes 
the  picture  as  seen  by  the  naked  eye  cannot  be  recognized 
as  tumor  at  all,  and  the  lesions  as  shown  at  autopsy  will 
be  interpreted  as  inflammatory  or  degenerative  processes,  — 
for  instance,  as  chronic,  indurative,  or  pneumonic  lesions. 
It  follows  from  this  that  at  every  autopsy,  even  at  those 
where  there  is  no  reason  to  suspect  the  presence  of  tumor,  a 
microscopic  examination  according  to  modern  methods  is 
necessary  for  every  portion  of  the  lungs  that  does  not  appear 
absolutely  sound  and  healthy. 

Passing  from  the  macroscopic  to  the  microscopic  study 
of  primary  maUgnant  neoplasms  of  the  limg,  manifold 
difficulties  in  determining  the  histological  structure  of  the 
tumor,  its  interpretation  and  classification,  are  encountered. 
As  the  simpler  group  of  these  tumors,  and  presenting  fewer 
of  these  difficulties,  sarcoma  will  be  first  discussed.  Hertz  ^ 
goes  so  far  as  to  deny  the  existence  of  primary  sarcoma  of  the 
lung,  claiming  that  every  sarcoma  found  in  that  organ  is 

*  Neubildungen  der  Lungen  in  Ziemssens  Handbuch,  1874,  Vol.  5. 


PATHOLOGY  43 

secondary.  It  must  be  admitted  that  primary  sarcoma  of 
the  lung  is  a  great  rarity.  The  writer  has  not  had  the 
good  fortune  to  observe  a  single  case.  Nevertheless,  it  has 
been  attempted  here  to  show  that  the  relation  of  primary 
sarcoma  of  the  limg  to  primary  carcinoma  of  that  organ  does 
not  differ  from  the  relation  which  sarcoma  bears  to  carcinoma 
in  general.^  This  conclusion  is  based  on  a  collection  of  ninety- 
four  cases  from  the  hterature  on  the  subject,  ninety  of  which 
have  been  listed  in  Table  II.  It  is  quite  possible  that  a  num- 
ber of  those  set  down  as  doubtful  in  Table  III  are  genuine 
sarcoma.  It  is  possible  also,  and  very  probable,  that  a 
great  many  cases  have  not  been  recognized  and  therefore  not 
recorded. 2  As  more  attention  is  paid  to  this  subject,  reports 
of  cases  are  pubhshed  in  greater  number  than  would  have 
been  thought  possible  some  years  ago.  It  would  have  been 
easy  to  increase  the  number  of  cases  on  Table  II  to  more 
than  one  hundred.  All  this  shows  that  the  beUef  in  the 
extreme  rarity  of  sarcoma  has  been  somewhat  exaggerated. 

It  has  been  shown  above  that  the  gross  pictures  presented 
by  sarcoma  may  differ  so  slightly  from  those  offered  by 
carcinoma  that  microscopic  examination  alone  would  serve 
to  differentiate  between  the  two.  It  may,  however,  be  said 
roughly  that  sarcoma  has  a  greater  tendency  to  spread 
toward  the  root  of  the  lung,  and  involve  from  there  the 
mediastinal  lymph  nodes  and  other  organs,  than  has  carci- 
noma. Melanotic  sarcoma  is  extremely  rare,  —  there  is,  in 
fact,  some  doubt  in  the  writer's  mind  that  it  occurs  at  all. 
The  dark  anthracotic  pigmentation  of  lungs  and  bronchial 
glands,  pathologically  more  prominent  perhaps,  may  erro- 
neously lead  to  the  suspicion  of  melanosis.  The  very  large 
and  massive  tumors  occupying  a  great  portion  of  the  chest 
have  just  been  referred  to.    They  are  occasionally  subject 

1  According  to  Williams  (loc.  cit.,  p.  377),  54.5%  of  all  tumors  are  car- 
cinoma, 9.4%  sarcoma,  24.7%  non-malignant,  and  11.4%  cysts.  These 
figures  corroborate  the  above  statement. 

2  A  quotation  from  Menetrier  (Lubin,  These  de  Paris,  1909,  Contributions 
k  I'Etude  du  Sarcome  primitif  du  Poumon)  seems  apt  enough  in  this  connec- 
tion: "Le  cancer  n'est  pas  une  forme  morbide  primitive;  c'est  un  aboutissant 
d'etats  pathologiques  multiples,  anterieurs  et  preparatoires." 


44     PRIMARY  MALIGNANT  GROWTHS  OF  THE  LUNG 

to  osseous  and  especially  to  calcareous  degeneration.^  A 
scrutiny  of  Table  II  shows  that  about  half  of  the  cases 
tabulated  are  of  this  massive  type.  Between  these  and  the 
more  infiltrating  forms  there  are,  of  course,  all  manner  of 
transitions.  An  especially  interesting  case  came  to  hand 
after  the  Tables  were  finished.  In  this  case  the  entire  left 
half  of  the  chest  was  filled  by  a  voluminous  mass,  dislocating 
the  heart,  impinging  on  the  right  lung,  and  depressing  the 
liver.  The  left  lung  was  almost  completely  replaced  by  a 
huge  tumor  which  pushed  the  remnants  of  the  pulmonary 
tissue  upward.  The  tumor  contained  a  cavity  in  the  midst 
of  soft  tumor  material.  The  duration  of  the  disease  was 
almost  three  and  a  half  years. ^  A  most  interesting  case, 
also,  is  that  reported^  of  a  male  thirty-three  years  old,  who 
entered  the  hospital  in  July,  1896.  He  had  been  sick  since 
the  previous  December  with  cough,  haemoptyses,  pains  in 
right  chest,  and  in  addition  bronzed  skin  and  bluish  sclerse. 
In  February,  1896,  he  was  seized  with  a  severe  pain  in  the 
right  leg,  especially  in  the  knee,  which  lasted  until  death. 
The  entire  right  side  was  more  painful  than  the  left;  no  pig- 
mentation in  the  mouth;  percussion  absolutely  flat  over  entire 
right  anterior  chest,  and  resistance  much  greater  than  normal; 
some  cavernous  breathing  below  the  right  clavicle,  otherwise 
absolute  silence  over  the  whole  right  posterior  lung;  sputum 
contained  nothing  characteristic.  The  autopsy  showed  an 
enormous  sarcoma  of  the  right  lung,  many  metastases  of 
liver,  pancreas,  etc.  Microscopically,  a  giant  celled  sarcoma 
of  mixed  type.  A  diagnosis  of  primary  tumor  of  the  lung 
had  been  made  during  life,  but  at  autopsy  the  authors 
were  inclined  to  consider  the  lung  tumor  secondary  and 
the  tumor  in  the  femur  as  primary;  in  the  first  place  on 
account  of  its  microscopic  structure,  —  the  mixed  giant 
celled  sarcoma,  —  the  giant  cell  being  more  common  in 

1  Chiari,  Table  III,  No.  4. 

2  Heilbron  et  Sezary,  Sarcome  primitif  du  poiimon,  Bull,  et  Mem.  de  la  Soc. 
Anatom.  de  Paris,  Ann^e  85,  No.  7,  p.  758. 

3  Packard  and  Steele,  Case  of  Sarcoma  of  the  Lungs,  with  symptoms  of 
Addison's  disease  with  involvement  of  suprarenal  capsules.  Med.  News, 
1897,  No.  11. 


PATHOLOGY  45 

bone;  furthermore,  the  advanced  condition  of  degeneration 
in  the  femur  beyond  that  of  the  lung.  For  this  reason  the 
authors  claim  the  tumor  in  the  lung  as  secondary.  This 
may  be  correct,  but  the  true  facts  cannot  be  obtained  with 
certainty.  If  it  is  secondary  in  the  lungs,  we  have  the  very 
unusual,  as  far  as  the  writer  knows,  the  unique,  occurrence 
of  a  secondary  sarcomatous  deposit  involving  only  a  single 
lung  and  assuming  such  huge  proportions  as  almost  to  occupy 
the  entire  lung.  It  might  be  interesting  to  refer  here  also  to 
a  publication  by  Eckersdorff.^  According  to  his  statistics 
1.5  per  mille  of  all  autopsies  are  primary  sarcoma  of  the 
lungs.  Eckersdorff  finds  up  to  the  year  1908  only  four 
cases  of  primary  sarcoma  of  the  lungs.  He  publishes  two 
cases,  one  of  a  man  fifty  years  old  living  rather  a  wild  life. 
In  November,  1902,  in  joke,  a  friend  gave  him  a  blow 
between  the  shoulder-blades  which  led  to  a  strong  desire 
to  urinate.  Next  day  he  felt  still  much  affected,  but  on 
second  day  entirely  well  again.  Soon  thereafter  he  began 
to  be  hoarse,  had  pains  in  region  of  heart  and  intermittency 
of  pulse.  The  most  interesting  part  of  the  later  history 
is  the  rapid  change  when,  after  considerable  dyspnoea, 
irregular  and  rapid  pulse,  urine  without  albumen,  enor- 
mous thirst,  the  patient  would  suddenly  get  better.  It 
was  not  until  late  in  the  course  of  the  disease  that  total 
dulness  of  left  lung  with  abolished  breathing  sounds  was 
discovered.  This  dulness  disappeared  quickly  with  the 
exception  of  one  place.  Later  on  there  was  a  sudden  dis- 
appearance of  the  pains.  Death  February  7th  in  collapse. 
The  diagnosis  during  life  was:  probable  neoplasm  in  the 
lung.  The  anatomical  diagnosis,  an  annular  carcinoma 
of  the  left  main  bronchus  with  obstruction  of  this  and  the 
formation  of  metastatic  deposits  in  the  lymph  nodes  and 
on  the  heart,  oedoema  of  both  lungs,  pneumonia  of  the  left 
lower  lobe,  and  dilatation  of  both  ventricles  of  the  heart. 
Microscopical  examination  showed  that  it  was  not  a  car- 
cinoma, but  a  sarcoma  of   small   round   cell   type.     The 

'  Zwei  Falle  von  primarem  Sarkom  der  Lunge,  Centralbl.  f.  allg.  Path., 
Vol.  17,  1906,  p.  355. 


46     PRIT^IARY  MALIGNANT  GROWTHS  OF  THE  LUNG 

histogenesis  cannot  with  certainty  be  determined.  The 
author  thinks  that  the  connective  tissue  of  the  bronchial 
mucosa  is  the  place  of  origin.  He  does  not  express  a 
positive  opinion  as  to  the  causal  effect  of  the  blow.  In 
a  second  case  the  origin  is  referred  to  the  interalveolar 
septa.  The  author  expresses  the  hope  that  in  future  the 
sputum  may  be  studied  more  carefully  in  such  cases. 

Another  case  which  appeared  after  the  Tables  were  finished 
may  be  mentioned  here,  though  not  a  sarcoma,  the  interest- 
ing feature  of  it  being  the  observation  of  the  blood.  Haemo- 
globin is  not  mentioned,  but  in  the  first  blood  count  the 
red  cells  are  reduced  to  3,886,100  and  the  leucocytes  are 
increased  to  19,840,  of  which  the  polynuclears  are  seventy- 
nine  per  cent.  A  second  blood  count  also  does  not  give 
the  haemoglobin.  The  red  cells  have  dropped  down  to 
2,926,400,  the  whites  have  increased  to  24,800,  and  the  poly- 
nuclears are  now  eighty-six  per  cent.  A  large  tumor  is 
found  with  cavities  supposed  to  involve  the  larger  bronchi 
and  the  hilus.  The  microscopical  analysis  shows  a  cancroid. 
Origin  from  the  bronchus  is  nevertheless  assumed. 

The  frequent  occurrence  of  primary  sarcoma  of  the  lungs 
in  the  form  of  huge  and  ponderous  tumors  is  also  corrob- 
orated by  Duran.i  Schech^  states  that  when  in  the  right 
lung,  the  favorite  seat  of  the  tumor  is  the  upper  lobe,  while 
in  the  left  lung  the  favorite  seat  of  tumor  is  the  lower  lobe, 
and  that  he  has  seen  the  tumor  primary  in  both  lungs  only 
twice.  Looking  over  Table  II  in  regard  to  this  point,  one 
will  find  that  there  is  no  such  difference,  but  that  tumor  in 
the  right  upper  or  left  lower  lobe,  and  the  converse,  occurs 
with  equal  frequency.  There  are  five  cases  cited  in  the 
Table  where  both  lungs  are  affected.  The  duration  of 
sarcoma  of  the  lungs  does  not  seem  to  differ  very  materially 
from  that  of  carcinoma.  There  are  fifty-two  cases  out  of  the 
ninety  in  Table  II  from  which  some  approximation  as  to 
their  possible  duration  may  be  reached.  Among  these  fifty- 
two^  the  shortest  period  of  duration  is  one  month  and  the 

^  Du  sarcome  primitif  du  poumon,  Th^se  de  Paris,  1893. 
« Table  II,  No.  78. 


PATHOLOGY  47 

longest  six  years,  the  average  being  about  four  and  a  half 
months,  as  compared  to  that  of  carcinoma,  the  average  for 
which  is  two  and  a  third  months.  It  is  evident  that  these 
averages  have  no  real  significance,  and  the  only  legitimate 
deduction  from  the  figures  is  that  primary  carcinoma  and 
sarcoma  of  the  lungs  are  of  indefinite  duration,  running  at 
times  a  very  rapid  course  and  again  assuming  the  character 
of  chronic  disease  and  lasting  for  many  years.  ^ 

The  histology  of  primary  sarcoma  of  the  lungs  offers  in 
the  main  nothing  peculiar  or  characteristic,  but  practically 
corresponds  with  the  histology  of  sarcoma  of  other  organs. 
It  has  been  said^  that  the  spindle  cells  occur  more  frequently 
than  any  other  type  of  cell.  Examination  of  Table  II  in 
regard  to  this  point  shows  only  sixty-eight  cases  available, 
as  in  the  remaining  twenty-three  there  was  no  clear  state- 
ment as  to  the  character  of  the  cells.  Out  of  these  sixty- 
eight  cases  just  half  were  of  the  typical  uncomplicated 
round  celled  variety,  fourteen  only  were  spindle  celled, 
seven  uncomplicated  lympho-sarcoma,  and  there  were  also 
a  few  mixed  tumors,  such  as  lympho-sarcoma  with  small 
round  cells,  with  spindle  cells,  etc.  It  seems,  therefore,  that 
round  celled,  and  not  spindle  celled,  sarcomata  are  by  far 
the  most  frequent.  Occasionally,  giant  cells  are  found.^ 
There  are  found,  also,  the  usual  combinations,  such  as 
myxo-sarcoma,  fibro-sarcoma,  and  others;  various  degenera- 
tions, as  mucoid,  colloid,  more  frequently  fatty,  and  also 
calcareous  and  osseous,  attributable  principally  to  the 
stroma;  occasionally  there  are  cystic  forms. 

The  histogenesis  is  still  obscure.  It  seems  certain  that 
a  great  many  of  the  pulmonary  sarcomata  take  their  origin 
from  the  root  of  the  lung,  probably  in  one  or  the  other  of  the 
smaller  or  smallest  of  the  peribronchial  glands,  growing  from 
there,  as  mentioned  before,  along  the  track  of  the  bron- 
chi, and  at  an  early  period  penetrating  a  larger  or  smaller 

^  For  further  details  regarding  duration  of  primary  sarcoma  of  limgs,  see 
Appendix  B. 

*  Schech,  loc.  cit. 

'  Packard  and  Steele,  loc.  cit.  Also  Colomiatti,  Table  II,  No.  14.  Also 
Klemm,  Table  IV,  No.  10. 


48     PMIvLmY  MALIGNANT  GROWTHS  OF  THE  LUNG 

bronchus,  obstructing  it,  and  thus  continuing  in  its  course 
through  the  lungs,  the  tissue  of  which  it  destroys  on  its 
way.  It  may  also,  it  is  said,  penetrate  through  the  pores 
of  the  septa  directly  into  the  alveoles.  The  large  massive 
tumors  almost  invariably  start  at  the  hilus.  It  is  assmned 
by  many,  though  not  yet  conceded  by  all,  that  sarcoma  may 
develop  from  the  interalveolar  septa  in  the  lung  itself.  The 
septa,  at  one  or  several  spots  becoming  sarcomatous,  may 
compress  the  pulmonary  alveoles  and  fill  with  tumor  material 
what  is  left  of  the  air-vesicles,  thus  forming  nodules  of  vary- 
ing size  which,  again  merging  into  similar  nodules,  can  form 
considerable  tumors.  The  lung  tissue  in  the  immediate  en- 
vironment of  these  nodular  tumors  is  usually  quite  healthy, 
or  evidences  only  minor  changes.  Microscopic  examination 
may  show  remains  of  septa  or  the  latter  may  have  been  de- 
stroyed altogether.  As  a  rule  there  is  no  open  communication 
with  the  bronchus,  but  bronchial  remnants  are  seen  within 
the  tumor.  In  some  instances  the  sarcomatous  tissue  does 
not  completely  destroy  the  septa,  so  that  the  alveolar  struc- 
ture in  some  places  at  least  remains  distinctly  visible.  The 
air-vesicles  are  then  filled  with  a  mass  of  polymorphous 
cells  which,  according  to  the  individual  bias  of  the  observer, 
may  pass  either  for  epitheUal  cells  or  for  deformed  sarcoma 
(round)  cells  or  for  endothelial  cells.  The  dispute  concerning 
endothelium  will  be  touched  upon  later.  For  the  present 
it  may  be  said  that  some  authors  consider  the  endothelium 
to  play  a  considerable  role  in  the  histology  of  sarcoma,  and 
Burkhardt,^  after  extensive  researches,  thinks  that  sarcoma 
and  endothelioma  are  not  to  be  separated  from  each  other, 
inasmuch  as  every  sarcoma,  besides  the  proliferating  cells 
of  the  connective  tissue,  contains  a  greater  or  less  proportion 
of  endothelia  of  the  lymph  spaces  as  well  as  adventitia  cells. 
All  sarcoma  are,  therefore,  according  to  him,  more  or  less 
endothelioma,  and  only  according  as  the  connective  tissue 
cells  or  the  endothelia  react  stronger  do  the  various  types 
stand  out.     This  is,  of  course,  a  very  extreme  point  of  view 

^  Sarkome  und  Endotheliome  nach  ihrem  path.-anatom.  und  klin.  Ver- 
halten,  Bnins  Beitr.  z.  klin.  Chir.  36,  1902. 


PATHOLOGY  49 

and  will  have  to  be  discussed  later  when  endothelioma 
is  touched  upon.  The  microscopic  picture  often  speaks 
for  this  theory,  as  it  presents  distinct  alveolar  structure 
with  much  enlarged  septa  consisting  of  spindle  cells  and 
alveoles  filled  with  polymorphous  cells.  It  is  this  type  of 
tumor  that  probably  comes  under  the  head  of  what  Virchow 
termed  carcinoma  sarcomatodes.^  The  case  of  Weichselbaum ^ 
seems  to  be  a  true  adeno-sarcoma.  Is  it  not  possible  that 
this  kind  of  tumor  resembles  those  produced  experimentally 
by  Ehrlich  and  his  school,  in  which  the  stroma  of  a  carcinoma 
was  ultimately  converted  into  genuine  spindle  or  round 
celled  sarcoma? 

Carcinoma.  The  epithelium  found  in  the  lungs  (lungs 
being  taken  in  the  broader  sense  and  including  the  bronchi) 
consists  of  cylindrical  epithelium,  cihated  as  well  as  not 
cihated.  The  ciliated  cells  form  the  hning  of  the  mucous 
membrane  of  the  larger  bronchial  tubes.  As  with  continued 
dichotomous  division  the  branches  of  the  bronchial  tree  be- 
come smaller,  so  the  high  ciliated  cells  become  lower,  the 
cilia  gradually  disappear,  and  the  very  smallest  bronchioles 
are  simply  lined  by  a  small,  low,  cuboid  epithelium  without 
cilia.  The  bronchial  epithelium  in  the  minutest  bronchioles 
is  by  gradual  transformation  changed  into  the  respiratory 
and  alveolar  epithelimn.  In  the  adult  this  consists  of 
fiat,  squamous  cells  resembling  endothelium.  They  line 
the  septa  and  the  pulmonary  alveoli.  The  endothelium 
itself,  those  cells  which  form  the  inner  coating  of  the  lymph 
vessels  and  spaces,  must  be  presently  considered  somewhat 
more  in  detail,  as  it  is  still  a  subject  of  dispute.  Cyhndrical 
epithelium  is  also  found  in  the  bronchial  mucous  glands. 
This  has  no  cilia  and  differs  in  no  way  from  the  ordinary 
cylindrical  cell  as  found  in  glands. 

Considering  only  the  very  limited  group  of  cells  that 
contribute  to  the  structure  and  formation  of  the  carcinoma 
of  the  lung,  it  is  often  surprisingly  difficult  to  distinguish 
the  kind  of  epithelial  cells  that  make  up  the  tumor,  and  its 

^  Bohme,  M.,  Primares  Sarco-Carcinom  der  Pleura,  Virchows  Archiv., 
Vol.  81,  1880,  p.  181.  2  Table  III,  No.  94. 

5 


50     PRIMARY  MALIGNANT  GROWTHS  OF  THE  LUNG 

structural  peculiarities,  and  to  understand  the  histogenesis. 
The  enormous  plasticity  of  the  epithelium,  the  influence 
which  territorial  hmitations,  intense  proliferation,  pressure 
upon  each  other,  and  various  other  intra-  and  extra-cellular 
changes  bring  to  bear  upon  the  cells,  —  all  these  features 
conspicuously  increase  the  difficulties.  It  may  really 
appear  at  times  as  if  there  were  no  specific  kinds  of  epithe- 
lium, but  that  the  epithelial  cell,  according  to  merely 
extrinsic  conditions,  might  assume  any  form,  cylindrical 
cells  being  transformed  into  pavement  cells,  pavement 
cells  into  horny  pearls,  etc.  One  is  frequently  at  a  loss  to 
decide  whether,  in  the  section  before  him,  the  cells  are  of 
epithelial  or  connective  tissue  origin,  whether  it  is  a  carci- 
noma or  a  sarcoma.  Frankel,  in  the  discussion  of  Simmond's 
paper,  ^  states  emphatically  that  great  difiiculty  is  often 
experienced  in  distinguishing  between  carcinoma  and 
sarcoma,  owing,  on  the  one  hand,  to  the  alveolar  structure 
of  the  lung  simulating  carcinoma,  and  on  the  other  hand  to 
the  almost  limitless  proliferation  and  change  of  form  of  the 
epithelia  suggesting  sarcoma.  A  good  example  of  this  is 
shown  in  Plate  3.  Here  the  cells  are  so  crowded,  the  prolif- 
eration is  so  rapid,  that  it  would  be  impossible  at  the  spot 
photographed  to  make  any  other  diagnosis  than  that  of  a 
small  round-celled  sarcoma.  No  one  would  easily  believe 
that  these  cells  are  mere  transformations  of  epithelial  cells 
and  that  the  tumor  is  a  true  carcinoma.  Plate  4  shows  the 
same  section  with  a  higher  power.  One  sees  a  great  variety 
of  polymorphous  cells,  some  of  which  resemble  epithelial, 
others  sarcoma  cells.  In  one  spot  a  mitosis  is  plainly  to  be 
seen.  Plate  5  is  a  section  of  the  same  tumor  from  another 
place,  photographed  with  a  moderate  magnification,  which 
plainly  demonstrates  the  alveolar  structure,  the  typical 
stroma,  and  in  several  places  undoubted  epithelial  cells. 
There  can  be  no  hesitancy  in  calling  this  tumor  a  carci- 
noma. Plate  6  is  a  section  from  the  kidney  of  the  same 
patient,  photographed  with  high  power  and  showing  most 

^  liber  die  Histologie  des  prim.  Lungenkrebses,  Miin.  Med.  Woch,,  1896, 
p.  189. 


PATHOLOGY  51 

beautifully  a  few  undoubted  epithelial  cells  just  after  their 
entrance  into  Bowman's  Capsule.  This  picture  may  serve 
to  remove  all  possible  doubt  as  to  the  true  natiire  of  the 
tumor. 

The  various  well-known  types  of  carcinoma  are  all  repre- 
sented. The  carcinoma  simplex.  Plate  7  is  a  good  illustra- 
tion of  this.  The  alveolar  structure  is  very  plain,  the  alveoles 
varying  in  size,  lined  with  cuboid  or  cylindrical  cells  and 
filled  with  polymorphous  cells  jumbled  together,  compressed 
out  of  shape  and  partly  degenerated  (horny,  mucoid,  colloid, 
fatty  degeneration,  etc.,  are  frequently  met  with).  The 
stroma  is  usually  rich  in  cells  and  here  and  there  a  lymph 
space  filled  with  epithelial  cells  is  seen.  It  is  very  interest- 
ing to  note  in  the  picture  a  tolerably  large  alveole  projecting 
its  epithelial  material  directly  into  a  lymph  vessel.  Plate  8 
shows  the  typical  glandular  carcinoma  without  any  distinc- 
tive features,  and  consisting  mostly  of  flat  and  cuboidal 
epithelial  cells  with  very  little  stroma.  In  this  section  there 
is  nothing  to  suggest  the  origin  of  the  tumor  from  the  lung. 
Plate  9  shows  the  same  form  of  carcinoma  with  smaller  and 
more  plexiform  alveolar  structure,  more  voluminous  and 
firmer  interstitial  tissue,  and  a  very  plain  demonstration  of 
the  infiltration  of  lymph  vessels  and  spaces  from  the  alveolar 
contents.  In  Plate  10  is  shown  a  good  example  of  a  can- 
croid with  the  characteristic  horny  epithehal  pearls.  The 
basilar  lining  of  cuboid  cells  is  in  this  section  not  very 
plain. 

The  cylindrical  celled  carcinoma.  Plate  11.  The  cells  are 
not  ciliated.  The  alveolar  structure  is  evident,  the  alveoles 
varying  in  size.  The  larger  ones  are  about  the  size  of  a 
moderately  large  bronchus,  and  it  is  obvious  that  they  are 
formed  by  the  confluence  of  a  number  of  smaller  alveoles. 
The  contents  of  these  larger  alveolar  spaces,  sometimes  sug- 
gesting small  cavities,  consist  of  cellular  and  mucous  detritus 
and  scattered  epithelial  cells  in  various  stages  of  degenera- 
tion. The  stroma  between  the  alveoles  generally  consists  of 
rather  soft  connective  tissue  containing  moderately  abun- 
dant connective  tissue  cells.    This  form  of  carcinoma,  occur- 


52     PRIMARY  MALIGNANT  GROWTHS  OF  THE  LUNG 

ring  as  it  does  quite  frequently,  is  considered  by  many 
pathologists  to  be  the  typical,  if  not  the  only  form,  in 
which  carcinoma  occurs  in  the  lungs.  It  is  demonstrable 
that  this  type  of  tumor  develops  from  the  cells  of  the 
bronchial  mucous  glands.  That  this  is  so  was  first  shown 
by  Langhans,^  whose  views  were  widely  accepted. ^  In 
Plate  12  there  is  seen  very  clearly  to  the  right  of  the  pic- 
ture a  dilated  bronchus  with  mucoid  detritus  in  its  interior 
and  a  partially  detached  epithelial  lining.  In  the  middle  of 
the  picture  are  shown  the  bronchial  epithelial  glands,  the 
majority  of  them  unchanged,  others  just  at  the  beginning 
of  carcinomatous  proliferation.  Toward  the  left  are  some 
alveoles  lined  with  cylindrical  cells  and  the  transition  from 
proliferating  bronchial  mucous  glands  to  carcinomatous 
alveoles  is  clearly  perceptible.  Plate  13  illustrates  similar 
conditions.  The  bronchial  cartilage  is  in  parts  destroyed 
and  there  are  similar  carcinomatous  degenerations  as  in  the 
preceding  figure.  Some  of  the  alveoles,  evidently  originat- 
ing from  degenerated  bronchial  mucous  glands,  contain  carci- 
nomatous epithelium,  not  typically  glandular,  but  exhibiting 
the  usual  character  of  pavement  epithelium. 

Carcinoma  may  also  develop  from  the  surface  epithelium 
of  the  bronchi.  It  is  still  a  matter  of  some  dispute  what 
kind  of  cells  are  characteristic  of  this  form  of  carcinoma. 
It  is  thought  by  competent  authorities  that  the  surface 
epithelium  of  the  bronchi  develops  a  carcinoma  of  alveolar 
structure  with  polymorphous  and  polyedric  cells  that  are, 
in  the  great  majority  of  cases  flat,  but  sometimes  varying 
numbers  of  cylindrical  cells  are  mingled  with  them.  Such 
forms  of  carcinoma  are  exemplified  by  Plates  8  and  9.  It 
was  contended  by  some^  that  the  carcinoma  just  described 
might  develop  from  the  bronchial  mucous  membrane,  but 
might  also  take  its  origin  from  the  flat  epithelium  of  the 
pulmonary  alveoles.    This  contention  caused  considerable 

1  Virch.  Arch.,  Vol.  53,  1871,  p.  470. 

2  Chiari,  Table  I,  No.  51;  Ebstein,  Table  I,  No.  75;  Stilling,  Table  I,  No. 
310,  and  others. 

3  Ehrich,  Table  I,  No.  77,  and  others. 


PATHOLOGY  53 

discord  among  the  few  pathologists  who  studied  the  subject. 
A  number  of  these  without  hesitation  considered  every  pul- 
monary carcinoma,  where  they  found  fiat  polyedral  epithe- 
lium, as  necessarily  derived  from  the  alveolar  cells.  A 
little  closer  study  showed  the  untenable  character  of  these 
theories.  It  is  unnecessary  to  enter  into  all  the  details  of 
the  discussion.  Some  considered  the  flat  epithelium  in 
pulmonary  carcinoma  extremely  rare,  others  considered  it 
very  frequent.  Frohhch,^  for  instance,  found  it  twelve 
times  among  sixteen  cases.  According  to  the  statistics  of 
Watsuji,2  32.2%  of  all  pulmonary  carcinomata  are  of  the 
pavement  cell  variety.  There  is,  however,  no  evidence  that 
these  carcinomata  develop  from  the  pulmonary  alveoles. 
On  the  contrary  there  is  considerable  evidence  against  the 
supposition.  It  is  now  held  that  carcinoma  starting  from 
the  pulmonary  alveoles  is  extremely  rare,  and  some  go  so 
far  as  to  deny  its  existence  altogether.  Marchand  and  his 
pupils  ^  succeeded  in  demonstrating  beyond  doubt  a  tumor 
starting  from  the  alveolar  respiratory  epitheUum.  The 
tumor  in  question  would  hardly  be  recognized  as  tumor  by 
the  naked  eye,  but  rather  suggested  the  opaque  and  some- 
what translucent  tissues  as  they  occur  in  chronic  broncho- 
pneumonia, and  the  structure  as  shown  by  the  microscope 
was  a  great  siuprise.  It  was  found  that  the  tumor  was 
made  up  of  cylindrical  cells  with  more  or  less  of  a  papillary 
arrangement.  As  the  respiratory  epithelium  in  the  embryo 
is  of  the  cylindrical  type,  the  occiu-rence  of  cylindrical  cells 
in  these  growths  is  not  surprising.  The  tumor  is  probably 
congenital.  Plate  14  shows  a  section  of  this  sort  of  tumor, 
in  which  remnants  of  alveolar  structure,  with  somewhat 
irregular  but  nevertheless  recognizable  high  cylindrical 
cells,  can  still  be  traced.  There  are  perfectly  clear  patches 
showing  papillary  arrangement. 

Neglecting  in  this  place  all  further  detail,  it  may  be 
briefly  stated  that  it  is  at  present  the  common  consensus  of 
opinion,  and  probably  justly  so,  that  the  great  majority  of 

1  Table  I,  No.  88.  *  Zeitschr.  f.  Krebsforsch.,  Vol.  I,  p.  445. 

*  Ejretschmer,  loc.  cit. 


54     PRIMARY  MALIGNANT  GROWTHS  OF  THE  LUNG 

primary  carcinomata  of  the  lungs  develop  from  the  bronchi, 
and  that  a  cancer  of  the  lung  is,  taken  strictly,  a  bronchial 
carcinoma;  that,  on  the  other  hand,  a  carcinoma  starting 
from  lung  tissue  itself  occurs,  but  is  extremely  rare,  and 
is  built  up,  not  of  flat,  but  of  cylindrical  epithelium. 


CHAPTER  VI 

PATHOLOGY  (Continued) 

\  NY  attempt  to  work  out  the  histogenesis  of  lung  tumors 
"^~*-  leads  at  once  to  troublesome  questions  concerning 
epithelium,  metaplasia,  and  other  fundamental  problems 
about  which  there  exist  great  differences  of  opinion  in  the 
pathological  world.  It  may  be  said  at  once  that  it  is  gen- 
erally impossible  to  determine  the  histogenesis  of  a  fully 
developed  lung  tumor  and  it  rarely  or  never  happens  that 
we  meet  with  a  tumor  so  small  that  its  very  beginnings  can 
be  clearly  seen.  Even  the  close  study  of  the  growing  edges 
of  the  tumor  will  give  no  satisfaction,  and  any  certainty 
with  regard  to  the  histogenetic  origin  of  the  majority  of  lung 
tumors  must,  for  the  present  at  least,  be  given  up  as  hope- 
less. Turning  to  epithelium,  it  is  at  this  moment  practically 
impossible  to  say  what  "epitheUum"  really  means  and  what 
its  relations  are  to  other  kinds  of  cells,  especially  to  endo- 
thehum.  The  literature  on  the  subject  of  endothelium  and 
its  relation  to  tumors,  as  well  as  to  acute  and  chronic  inflam- 
mations in  adult  tissue  and  its  embryonal  history,  is  really 
enormous,  and  no  attempt  at  even  a  sketch  can  be  made 
here.  The  work  of  Borst^  in  his  large  treatise  on  tumors, 
and  his  several  other  separate  publications, ^  and  the  critical 
compilations  of  Monckeberg,'  go  deeply  into  the  question 
of  endothelioma,  while  Volkmann,^  and  before  him  Kolaczek,^ 
have  done  fundamental  work  in  the  study  of  these  tumors. 
Leaving  this  mass  of  literature  to  those  specially  interested, 
it  is  important  to  arrive,  at  the  very  beginning,  at  some  un- 

^  Lehre  von  den  Geschwiilsten,  Wiesbaden,  1902. 
2  Das  Verhalten  der  Endothelien,  Wurzburg,  1897,  and  others. 
'  Lubarsch,  Ergebnisse,  10  Jahrg.,  Wiesbaden,  1906. 
*  Deut.  Z'tschrift  f.  Chir.,  Vol.  XLI,  1895. 
6  Deut.  Z'tschrift  f.  Chir.,  Vols.  IX  and  XIII,  1878  and  1880. 

55 


56     PRIMARY  MALIGNANT  GROWTHS  OF  THE  LUNG 

derstanding  of  the  nature  of  epithelial  cells.  It  is  generally 
accepted  that  epithelium  assumes  various  forms  differing  in 
morphological  structure  and  in  physiological  function.  The 
forms  recognized  by  all  are:  (1)  cylindrical  epithelium,  which 
is  differentiated  into  several  species :  (a)  endowed  with  cilia 
upon  which  certain  physiological  motor  functions  depend, 
and  (6)  without  cilia,  dispersed  in  a  single  layer  or  in  several 
strata,  serving  as  an  inner  coating  to  numerous  hollow 
organs,  and  lastly,  (c)  glandular  cylindrical  epithelium,  to 
which  are  allotted  duties  of  secretion  and  excretion;  (2)  fiat, 
squamous,  or  pavement  epithelium,  arranged  either  in  single 
layers  or;  in  numerous  strata  and  modified  in  its  morpho- 
logical structure  according  to  the  physiological  function 
which  it  is  called  upon  to  perform.  The  lining  of  numerous 
internal  organs  consists  of  this  type  of  epithelium.  The 
epidermis  which  protects  the  surface  of  the  entire  common 
integument  is  in  the  main  built  up  of  such  cells,  specially 
differentiated  as  to  their  structure  and  chemical  constitu- 
tion (kerato-hyalin,  intra-cellular  structure,  and  protoplas- 
matic bridges).  No  further  detailed  description  of  epithelial 
cells  is  necessary.  Until  very  recently  it  was  accepted  as 
a  fact  that  the  three  germinal  layers  were  the  dominant 
factors  in  the  histogenesis  of  all  the  tissues  and  organs  in 
intra-  as  well  as  extra-uterine  life.  All  the  epithelium  that 
was  needed  for  the  viscera  of  the  chest  and  abdomen  was 
supposed  to  be  furnished  by  the  entoderm.  The  epithelium 
of  the  common  integument  and  of  several  other  organs 
closely  connected  with  the  outer  surface  is  referred  to  the 
ectoderm.  There  is  besides  this  a  certain  class  of  flat  cells 
bearing  nearly  all  the  hallmarks  of  genuine  flat  epithelial 
cells,  which  are  universally  found  in  the  body  as  a  lining 
of  the  great  lymphatic  cavities  (pleura,  peritoneum,  etc.). 
The  inner  coat  of  the  arteries  and  veins  and  the  perivas- 
cular lymph  spaces,  as  well  as  all  lymph  spaces  throughout 
the  body,  are  lined  with  this  peculiar  epithelium.  Its  origin 
is  said  to  be  from  the  mesoderm,  the  mesoderm  being  the 
third  germinal  layer,  from  which  the  fibrous  and  connective 
tissue,  the   bones,   cartilages,   elastic   fibres,  etc.,  —  aptly 


PATHOLOGY  (Continued)  57 

called  by  the  Germans  ''Stiitzgewebe,"  —  are  said  to  origi- 
nate. These  cells  just  mentioned  as  coming  from  the  meso- 
derm could  not  be  classified  as  genuine  epithelium  and 
were  therefore  called  by  His  endothelium.  They  showed, 
on  the  one  hand,  close  connection  with  the  connective  tissue 
cells,  with  which,  indeed,  they  have  much  in  common,  espe- 
cially the  property  of  forming  fibro-plastic  cells.  There 
are  many  tumors  that  are  supposed  to  be  developed  from 
the  endothelium  and  are  therefore  named  endothelioma. 
These  are  usually  non-malignant,  but  there  are  also  malig- 
nant forms  of  endothelioma.  Borst  and  his  followers  have 
also  not  infrequently  found  endothelioma  as  a  primary 
malignant  neoplasm  in  the  lung.  The  writer  himself^  was 
at  one  time  convinced  of  the  occurrence  of  primary  malig- 
nant endothelioma  in  the  lungs,  but  has  since  been  forced 
to  change  his  opinion. 

At  the  present  writing  opinions  as  to  the  embryonal 
development  of  the  so-called  endothelium  are  extremely 
perplexing.  The  doctrine  that  the  endothelium,  as  well 
as  the  connective,  osseous,  and  other  specific  elements, 
are  derived  from  the  mesoderm,  is  becoming  more  and 
more  discredited.  Hertwig^  derives  the  mesoderm  from 
the  primary  entoderm,  and  according  to  him,  at  a  very 
early  stage  independent  mesenchym  germinal  cells  emigrate 
and  proliferate  in  the  spaces  between  the  ento-  and  ecto- 
derm, and  thus  form  the  basis  for  the  development  of  the 
connective  tissue  substances  and  blood.  Schultze,^  on  the 
other  hand,  derives  the  mesoderm  from  the  ectoderm,  and 
according  to  him  nearly  all  the  cells  of  the  mesoderm  possess 
considerable  mobiUty  of  their  own,  so  that  they  wander 
through  all  the  organs  developed  from  either  of  the  germinal 
layers.  It  will  be  seen  by  these  two  quotations  how  unsatis- 
factory as  yet  the  embryonal  history  of  endothelium  is.  It 
will  also  be  seen  that  embryology  is  tending  more  and  more 

^  I.  Adler,  Remarks  on  Primaxy  Endothelioma  of  the  Lung,  Pleura,  etc., 
Journal  of  Medical  Research,  VI,  1901. 

*  O.  Hertwig,  Lehrbuch  d.  Entwicklungsgeschichte,  1896. 

*  O.  Schultze,  Grundriss  der  Entwicklungsgeschichte,  Leipzig,  1896. 


58     PRIMARY  MALIGNANT  GROWTHS  OF  THE  LUNG 

toward  giving  up  the  mesoderm  as  a  primary  germinal  layer 
and  is  depending  more  and  more  upon  the  ento-  and  ecto- 
derm, with  only  secondary  and  varying  assistance  from  a 
secondary  mesoderm.  It  is  impossible  to  go  further  into 
details.  Let  it  suffice  to  say  that  at  present  there  is  little 
doubt,  though  the  various  workers  on  this  subject  have  not 
arrived  at  a  uniform  opinion  as  to  what  cells  should  be  classed 
as  endothelium  and  what  as  epithelium,  that  there  is  a  form 
of  cell  which  may  rightly  be  called  endothelium,  which  occu- 
pies a  unique  position  in  so  far  that  it  lines  the  banks  of 
seas  and  streams  of  fluid,  where  it  is  not  only  acting  as  a 
mere  mechanical  agent,  but  has  certain  other  physiological 
properties  which  will  be  touched  upon  presently. 

Suppose  the  endothelium  to  be  derived  from  the  meso- 
derm and  to  be  an  integral  part  of  the  connective  tissue 
system,  it  follows,  and  rather  absurdly,  that  a  tumor  pos- 
sessing alveolar  structure  and  cells,  not  to  be  distinguished 
from  the  true  epithelial  (carcinomatous)  cells, — a  neoplasm, 
in  short,  that  acts  altogether  like  a  carcinoma,  —  must  be 
classed  among  the  malignant  connective  tissue  tumors;  in 
other  words,  must  be  called  a  sarcoma.  Thus  Remak, 
Thiersch,  Billroth,  and  Waldeyer  classed  as  sarcoma  all 
tumors  that  develop  in  localities  where  normally  no  epithe- 
lium is  found.  This  may  in  part  be  responsible  for  such 
designations  as  adeno-sarcoma,  alveolar  carcinoma,  lympho- 
sarcoma, etc.  Koster^  does  not  employ  the  term  ''endo- 
thelioma," but  assumes  that  all  carcinomata  take  origin 
from  the  lymph  vessels.  Of  late  the  opinion  is  gaining 
ground  that  the  intimate  structure  of  the  tumor  is  not 
dependent  upon  certain  phases  of  embryological  develop- 
ment nor  upon  the  morphological  relations  of  the  three 
germinal  layers.  It  is  held  that  whatever  tumor  possesses 
carcinomatous  structure  and  behaves  clinically  as  a  carci- 
noma is  a  carcinoma,  no  matter  whether  its  component 
epithelial  constituents  be  derived  from  the  mesoderm,  the 
entoderm,  or  the  ectoderm.  In  other  words,  it  is  said 
that,  .while  the  germinal  layers  are  of  utmost  importance 

1  Die  Entwicklung  der  Carcinome  und  Sarcome,  Wiirzburg,  1869. 


PATHOLOGY  (Continued)  59 

as  regards  differentiation,  topography,  and  ultimate  devel- 
opment and  function  of  the  tissues,  their  influence  to  a 
great  extent  ceases  when  the  organism  is  complete  and  the 
foetus  is  fully  developed.  Extra-uterine  pathology  should 
not  be  tyrannized  over  by  embryology.^  Klaatsch^  also 
points  out  that  the  concept  of  a  mesoderm  is  gradually 
disappearing  and  that  the  ectoderm  is  of  paramount 
importance.  He  shows,  moreover,  the  necessity  of  being 
guided  in  one's  judgment  more  by  the  physiological 
requirements  and  functions  than  by  the  merely  morpho- 
logical and  embryological  point  of  view.  He  demonstrates 
convincingly  that  the  morphological  character  of  cells  may 
be  changed  to  a  considerable  extent,  consequent  upon  changes 
in  the  surrounding  tissues,  especially  when  gaps  in  the  con- 
tinuity of  the  tissues  are  formed.  He  is  totally  opposed  to 
a  classification  of  tumors  in  their  relations  to  the  three 
germinal  layers.  It  is  to  be  noted  that  both  functionally 
and  physiologically  the  endothelium  appears  closely  related 
to  typical  epithelium. 

It  is  not  necessary  to  go  into  all  the  finer  distinctions 
between  endothelium  and  epithelium.  It  is  best,  in  the 
opinion  of  the  writer,  to  agree  with  Borst  that  there  are 
tumors  undoubtedly  taking  origin  from  endothelium,  and 
as  the  endothelium  occupies  a  peculiar  position,  on  the 
one  hand  appropriating  to  itself  some  of  the  functions  of 
epithelium,^  on  the  other  hand  being  intimately  associated 
with  connective  tissue,  even  forming  fibro-plastic  cells,  it 
is  best  to  call  these  tumors  by  the  special  name  of  endothe- 
Uomata.  That  there  are  malignant  endotheliomata,  we 
cannot  doubt,  such  perhaps  as  the  much  discussed  primary 
cancer  of  the  pleura,  concerning  which  there  is  still  no  unity 
of  opinion  and  a  lack  of  clear  and  sharp  definition.    This  is 

^  Marchand,  Uber  die  Beziehungen  der  path.  Anatomie  zur  Entwicklungs- 
geschichte,  besonders  der  Keimblattlehre,  Verhand.  Deut.  Path.  Ges.,  II, 
1900,  pp.  38  ff. 

2  t)ber  den  jetzigen  Stand  der  Keimblattfrage  mit  Rucksicht  auf  die  Patho- 
logie,  Miinch.  Med.  Woch.,  1899,  N.  6,  p.  169. 

^  Haidenhain,  Verhand.  des  X.  internat.  Congresses,  Berl.  1891,  Vol.  II; 
also  Archiv.  f.  Physiol,  v.  Pfltiger,  Vol.  49, 1891,  and  Vol.  56, 1894;  also  Orlow, 
Recklinghausen,  Adler  and  Meltzer,  Meltzer,  and  others. 


60     PRIMARY  MALIGNANT  GROWTHS  OF  THE  LUNG 

shown  by  the  various  names,  as  for  instance  ''lymphangitis 
carcinomatodes " ^  or  "lymphangitis  prolif erans. " ^  As  to 
the  lung,  however,  the  writer  has  not  as  yet  been  so  fortunate 
as  to  be  able  to  diagnosticate  an  endothehoma  of  the  lung, 
though  Borst  and  his  pupils  and  others^  have  published  a 
number  of  cases. 

If  one  beheves,  as  does  the  writer,  that  these  malignant 
tumors,  carcinoma  and  others,  grow  not  peripherically, 
but  centrally,  out  of  themselves,  as  it  were,'*  then  the 
mere  fact  of  the  lymph  spaces  and  lymph  vessels  at  the 
periphery  of  the  growth  being  filled  with  endotheUal  cells 

1  Schottelius,  Table  I,  No.  289. 

2  A.  Frankel,  tlber  primaren  Endothelkrebs  der  Pleura,  Berl.  Klin.  Woch., 
1892,  21  and  22.  In  this  connection  it  might  be  well  to  mention  the  case  of 
Bostrom  (Das  Endothelcarcinom,  Diss.  Erlangen,  1876).  It  concerns  a  female 
twenty-eight  years  of  age  who  had  complained  of  no  lung  symptoms  whatever, 
but  who  suffered  mainly  from  the  stomach,  and  the  diagnosis  of  ulcer  of  the 
stomach  was  made.  She  died  suddenly  from  profuse  gastric  hgemorrhage.  At 
autopsy  the  ulcer  of  the  stomach  was  found  and  carefully  examined,  by  as  high 
an  authority  as  Zenker,  and  no  trace  of  anything  that  could  be  taken  for  car- 
cinoma was  detected.  Nevertheless,  besides  about  half  a  litre  of  bloody  sermn 
in  both  pleural  cavities  without  any  adhesions  of  the  lungs,  there  was  extensive 
carcinomatous  lymphangitis  on  the  pleura  of  both  sides  and  carcinomatous 
infiltration  of  the  bronchial,  tracheal,  and  retroperitoneal  glands.  Cases  of 
carcinoma  of  the  stomach  with  extensive  carcinomatous  lymphangitis  cover- 
ing the  lungs  have  been  frequently  reported  (Hilliarie,  I'Union  m4d.,  1874,  Nos. 
53,  54,  and  55;  Frantzel,  Charite-Annalen,  1878,  III,  306;  Debove,  Gas. 
Hebd.,  1879,  N.  43,  p.  688).  But  in  these  cases  there  was  usually  a  con- 
spicuous primary  carcinomatous  nodule  to  be  found  in  the  stomach.  In  this 
case  of  Bostrom's  we  have  a  practically  certain  assurance  that  there  was 
no  carcinoma  in  the  stomach.  By  means  of  very  careful  examination,  the 
bronchial  mucous  glands,  the  bronchial  and  alveolar  surface  epitheUum  could 
be  positively  excluded,  and  the  author,  after  most  painstaking  study,  by  means 
of  serial  sections  of  both  pleura,  comes  to  the  conclusion  that  the  pleural  affec- 
tion has  nothing  whatever  to  do  with  the  gastric  ulcer,  but  is  an  independent 
carcinoma  of  the  endotheliima  of  the  pleural  lymph  vessels. 

3  Wack,  Ein  seltener  Fall  von  primarem  Endotheliom  der  Lunge,  Diss. 
Wurzburg,  1898;  Klemm,  "Cber  ein  primares  Endotheliom  der  Lunge,  Diss. 
Miinchen,  1905;  Bostrom,  Endothelcarcinom  der  Lunge,  Diss.  Erlangen,  1876; 
Cahen,  Diss.  Wurzburg,  1896;  Neelsen,  Deut.  Arch.  Klin.  Med.,  Vol.  31, 
p.  375. 

*  Borrman  (Die  Entstehung  und  das  Wachstum  des  Hautcarcinoms,  Z.  f. 
Krebsforsch.,  II,  1904)  is  an  enthusiastic  adherent  of  imi-central  or  possibly 
multi-central  growth  of  carcinoma.  He  calls  attention  justly  to  the  fact  that 
nobody  has  ever  yet  seen  the  conversion  of  a  normal  epithelial  cell  into  a  can- 
cerous epithelial  cell,  and  as  his  material  consisted  of  carcinoma  of  the  skin 
in  its  very  earliest  stages  of  development,  his  findings  possess  considerable 
weight. 


PATHOLOGY  (Continued)  61 

means  nothing  as  to  histogenesis,  while  on  the  other  hand 
it  will  never  be  possible  to  study  a  tumor  at  a  stage  early 
enough  to  show  a  possible  development  of  the  endothelium 
into  maUgnant  cells.  Thus  the  diagnosis  of  primary  endo- 
thelioma of  the  lungs  is  at  present  not  possible,  and  it  is 
preferable  to  call  these  tumors,  not  endothelioma,  or  sar- 
coma, on  purely  theoretical  grounds,  but  carcinoma,  if  they 
are  built  and  act  like  one,  and  sarcoma  imder  similar 
conditions. 

There  are  many  microscopic  pictures  which  are  adduced 
as  characteristic  of  endothelioma,  especially  those  show- 
ing ramifications  simulating  a  network  of  deep  interlacing 
meshes,  strongly  suggesting  a  system  of  lymphatics,  more  or 
less  completely  filled  with  fiat,  endothelial-like  cells.  Plate 
15,  taken  from  the  same  tumor  as  Plate  9,  shows  this  rami- 
fication. Neither  Plate  9  nor  Plate  15  can  possibly  be  taken 
for  an  endothelioma,  as  other  parts  of  the  same  tumor  show 
typical  carcinoma.  In  the  same  way  Plate  16  shows  very 
prettily  the  injection  of  the  lymph  vessels  and  lymph  spaces 
with  carcinomatous  material,  but  it  is  from  the  same  tumor 
from  which  Plate  7  is  taken,  in  which  was  shown  the 
mechanical  injection  of  cells  from  a  large  typical  carci- 
nomatous alveolus  into  a  lymph  vessel,  and  it  is  not  possi- 
ble to  prove,  with  any  kind  of  magnification,  that  lymph 
endothelium  was  converted  into  carcinomatous  cells. 


CHAPTER  VII 

PATHOLOGY  (Continued) 

THE  aphorism  of  Bard/  "Omnis  cellula  e  cellula  ejusdem 
generis,"  has  been  mentioned.  If  each  kind  of  epithe- 
lium be  considered  a  specific  genus,  then,  according  to  him, 
cyhndrical  epitheHum  should  produce  only  cylindrical  epi- 
thelium; cuboid,  or  fiat,  or  horny,  should  always  and  under 
all  conditions  produce  a  similar  kind  of  epithelium.  It  soon 
became  evident,  however,  that  histology  did  not  completely 
bear  out  the  theory  of  the  strict  and  hmited  production 
of  cells  of  a  certain  character  and  structure  from  cells  of 
identically  the  same  character  and  structure.  A  long,  and 
at  this  writing  still  unsettled,  discussion  has  taken  place 
concerning  these  questions,  which  are  summarized  under 
the  title  of  '^ Metaplasia."  It  is  necessary  to  touch  briefly 
on  some  of  the  problems  of  metaplasia  in  order  to  obtain 
a  proper  notion  of  certain  changes  in  structure  and  char- 
acter of  the  cells  that  occur  here  and  there,  perhaps  not 
infrequently,  in  lung  tumors. 

Virchow,  as  is  well  known,  assigned  a  very  great  role  to 
metaplasia  in  pathology,  which  meant  for  him  something 
entirely  different  from  what  is  understood  to-day  by  the 
term.  He  attributed,  especially  to  the  connective  tissue 
cells,  all  sorts  of  possible  metaplastic  changes,  deriving 
osseous  tissue  therefrom  as  well  as  the  epithelial  cells  of 
carcinoma.  It  is  useless  to  enumerate  the  multitude  of 
pathologists  who  have  devoted  time  and  no  slight  labor 
to  this  question  of  metaplasia.  Opinions  differ  as  to 
whether  such  a  process  actually  exists,  and,  if  it  does 
exist,  what  the  meaning  of  the  process  is.  Ribbert  defines 
metaplasia  as  a  sort  of  regression,  the  cells  losing  their  speci- 
ficity and  attaining  a  simpler  structure,  or  in  other  words 

1  Loc.  cit. 
62 


PATHOLOGY  (Continued)  63 

returning  to  some  lower  state  of  differentiation  through 
which,  in  the  regular  course  of  development,  they  had 
already  passed,  and  this  without  regaining  new  properties. 
Hansemann  speaks  of  histological  accommodation  and  of 
anaplasia  as  being  a  lower  grade  of  differentiation  along 
embryological  lines,  to  which  the  metaplastic  cells  return. 
It  is  a  mooted  point  whether  this  metaplasia  of  the  cells 
proceeds  under  the  laws  of  strict  embryonal  development 
and  is  ruled  by  the  theory  of  the  three  germinal  layers.  If 
this  hypothesis  were  true,  then  the  metaplastic  alterations  to 
which,  say,  an  entodermal  epithelial  cell  is  subjected  would 
result  only  in  such  types  of  cell  as  normally  originated  from 
the  entoderm. 

On  the  other  hand,  it  is  maintained  that  metaplasia  is 
entirely  independent  of  embryonal  influences  and  that 
the  alterations  in  the  character  of  the  cell  are  produced 
by  mechanical  and  physical  conditions  and  in  a  great 
measure  by  causes  as  yet  unknown.  Finally,  there  is  a 
theory  entertained  by  many  that  the  so-called  metaplasia 
of  cells  and  tissues,  especially  when  occurring  in  tumors,  is 
the  outcome  of  congenitally  displaced  germinal  remnants.^ 
It  is  not  necessary  to  go  into  further  details  on  this  point. 
For  further  reference  to  these  questions  in  regard  to  tumors 
see  Lubarsch.2  Most  important,  and  throwing  light  also  on 
the  metaplasia  in  tumors,  is  the  work  of  Schridde.^  Speak- 
ing only  for  lung  tumors,  and  indifferent  to  what  may  take 
place  in  other  tumors  or  organs  with  reference  to  metaplasia, 
it  is  to  be  noted  that  only  such  cells  can  justly  be  considered 
as  metaplastic  cells  that  reproduce  not  only  the  superficial 
character  of  the  cells,  such  as  localization,  general  appear- 
ance, etc.,  but  the  cell  must  exhibit  the  intimate  and  charac- 
teristic structure  of  the  type  of  cells  which  is  supposed  to  be 
represented.    Thus,  an  ordinary  flat  epithelium  can  by  no 

1  Ernst,  Table  I,  No.  82. 

*  Lubarsch,  Die  Metaplasiefrage  und  ihre  Bedeutung  fur  die  Geschwulst- 
lehre,  Arbeiten  aus  der  path.  Anatom.  Abteilung  des  Kgl.  Hyg.  Institut  in 
Posen,  1901,  N.  305  ff. 

'  Schridde,  Die  Entwicklungsgeschichte  des  menschlichen  Speiserohren- 
epithels  und  ihre  Bedeutung  fur  die  Metaplasielehre,  1907;  Die  Ortsfremden 
Epithelgewebe  des  Menschen,  Jena,  1909. 


64     PRIMARY  MALIGNANT  GROWTHS  OF  THE  LUNG 

means  be  considered  as  an  epidermal  cell  unless  it  shows  the 
pecuhar  structm-e,  the  fibres,  and  protoplasmatic  bridges 
of  the  latter.  A  high  cuboid  or  a  laterally  compressed 
flat  cell  is  not  converted  into  a  cylindrical  cell  unless  it 
shows  at  least  some  of  the  typical  characteristics  of  the 
latter,  —  the  nucleus  at  the  base,  the  colloid,  mucoid,  or 
other  secretion,  etc.  It  is  reasonable  to  assume,  and  seems 
to  be  the  result  of  common  experience,  that  the  nearer  the 
epithelia  are  related  to  each  other,  the  more  readily  they 
will  interchange  in  form  and  structure.^  The  transforma- 
tions of  one  sort  of  epithelium  into  another,  usually  of 
cylindrical  or  cuboid  epithehum  into  squamous  epithelium, 
as  has  been  frequently  found  in  many  kinds  of  inflamma- 
tory processes,  in  granulations,  in  pneumonias, ^  in  the  gall 
bladder,^  in  the  urinary  bladder,  in  the  uterus,  in  the  pan- 
creas,^ and  other  organs,  are  well  known.  They  are  usually 
the  results  of  acute  or  chronic  inflammations.  It  would 
indeed  be  strange  if  similar  metaplasia  of  the  epithelium 
were  not  also  found  in  the  bronchi  and  in  the  lungs.  Under 
purely  physiological  conditions  and  under  perfectly  normal 
development,  certain  epithelial  changes  in  the  bronchi  are 
regularly  found.  The  largest  and  larger  bronchial  tubes 
are  lined  with  ciUated  cylindrical  epithehum.  In  the  smaller 
orders  of  the  bronchial  tubes  these  cylindrical  cells  lose  their 
ciha.  In  still  smaller  orders  the  cells  become  cuboid,  and 
finally,  and  without  break  in  the  continuity,  the  very  small- 
est bronchioles  and  the  pulmonary  alveoles  are  lined  with 
flat  epitheUal  cells.  Metaplastic  changes  in  the  epithelium 
under  pathological  conditions  are  shown  by  the  work  of 
Kitamura,^  who  finds  in  almost  every  grade  of  catarrhal 

1  Let  it  be  understood  that  even  in  the  question  of  metaplasia,  the  speci- 
ficity of  cells  as  postulated  by  Bard  is  still  maintained  to  a  certain  extent. 
Metaplasia  can  take  place  only  among  cells  embryologically  closely  related. 

2  Conf.  the  work  of  Friedlander,  tjber  Epithelwucherimg  und  Krebs,  Strass- 
burg,  1877,  57  S.  mit  2  Tafeln. 

»  Dietz,  Virch.,  Arch.,  Vol.  164,  p.  381. 

*  Lewisohn,  Zwei  Seltene  Carcinomfalle  zugleich  ein  Beitrag  zur  Meta- 
plasiefrage,  Z'tschrift  f.  Krebsforsch.,  Ill,  1905,  p.  528. 

^  Kitamura,  Uber  secundare  Veranderungen  der  Bronchien  und  einige 
Bemerkungen  uber  die  Frage  der  Metaplasie.,  Virch.  Arch.  190,  1907,  p.  160. 


PATHOLOGY   (Continued)  65 

inflammations  of  the  severer  types,  and  especially  in  tuber- 
culosis, the  transformation  of  single  layers  of  cyhndrical 
ciliated  cells  into  cuboid  or  polygonal  cells.  He  does  not 
consider  this  a  true  metaplasia,  but  simply  a  change  in  form, 
a  "histological  accommodation"  in  the  sense  of  Hansemann.^ 
On  the  other  hand  he  finds  genuine  stratified  epidermal  epi- 
thelium with  typical  keratohyalin  in  the  uppermost  strata. 
This  occurs  in  the  large  bronchi  that  are  in  open  communica- 
tion with  tubercular  cavities.  Later,  islets  of  this  epidermal 
epithelium  are  found.  There  are  many  other  metaplasias 
throughout  the  bronchial  system,  such  as  chalky  degenera- 
tions and  the  formation  of  bone  in  the  bronchial  wall,  etc. 
These  metaplasias  seem  to  occur  very  frequently  as  phe- 
nomena secondary  to  tuberculosis.  In  this  connection,  too, 
there  is  the  work  of  McKenzie.^  His  conclusion,  after  very 
careful  study  of  four  cases  in  very  young  children,  —  the 
oldest  only  two  years  old,  —  is  that  real  genuine  metaplasia 
exists.  Not  only  chronic  inflammatory  processes,  as  Sim- 
monds  beheves,  but  also  acute  inflammations  in  the  lungs 
may  lead  to  metaplasia.  The  existence  of  such  islets  of 
pavement  epithelium  in  the  lungs  after  acute  inflammation 
may  have  some  connection  with  the  development  of  pavement 
celled  cancer  in  the  lungs.  The  assumption  of  dislocated 
germinal  cells  is  not  needed  to  explain  the  development  of 
pavement  epithelium  cancer  in  the  lungs. 

Eichholz,^  in  his  very  excellent  experimental  researches 
concerning  the  conversion  of  the  epidermis  into  mucous  mem- 
brane, and  conversely,  is  inclined  to  think  that  metaplasia 
is  not  to  be  excluded  with  certainty,  but  on  the  whole  it 
does  not  seem  likely  to  him.  In  most  of  the  cases  where 
true  epidermis  was  formed  it  could  be  demonstrated  that  it 
was  due  to  a  proliferation  of  the  epidermis  from  without. 

1  Loc.  cit. 

2  Ivy  McKenzie,  Epithelmetaplasie  bei  Bronchopneumonie,  Virch.  Arch. 
190,  p.  351.  (Note,  by  the  author.  —  We  know  of  many  cases  of  conversion 
of  cyhndrical  into  pavement  epithehum;  we  know  of  none  as  yet  of  pavement 
into  cyhndrical  epithehum.) 

'  Eichholz,  Experimentelle  Untersuchungen  iiber  Epithelmetaplasie,  Lan- 
genbecks  Arch.  f.  klin.  Chir.,  Vol.  65,  p.  959. 
6 


66     PRIMARY  MALIGNANT  GROWTHS  OF  THE  LUNG 

Cylindrical  epithelium,  according  to  him,  is  able  to  produce 
epidermis.  If,  however,  epidermis  occurs  in  tissue  of  cylin- 
drical epithelium,  it  is  to  be  explained  either  through  the 
proUferation  of  the  epidermal  epithelium  from  without  or  by 
the  assumption  of  a  dislocated  embryonal  germ. 

It  is,  therefore,  not  difficult  to  explain  the  occurrence  of 
true  cancroid,  to  use  the  old  name,  —  that  is  to  say,  of 
nodules  consisting  of  typical  epidermal  cells  with  the  charac- 
teristic structure  and  the  formation  of  cancer  pearls.  It 
appears  natural,  too,  according  to  the  views  of  Kitamura, 
that  these  cases  generally  occur  in  connection  with  tubercu- 
losis, as  in  the  cases  of  Friedlander,^  Perrone,^  Gougerot,' 
and  a  number  of  others.  The  tumor  either  came  from  with- 
out and  penetrated  through  the  wall,  and  thus  projected  into 
the  tubercular  cavity,*  or  developed  directly  from  the  wall 
of  the  cavity.  In  the  case  of  Ernst  ^  the  cancroid  took  its 
origin  from  the  wall  of  the  main  bronchus  of  the  right  upper 
lobe.  As  from  this  location  no  epidermal  tissue  could 
normally  be  expected,  Ernst  attributed  his  tumor  to  develop- 
ment from  a  germinal  remnant.  In  view  of  this  widespread 
instability  in  the  types  and  forms  of  the  epithelial  cells  and 
the  apparent  lawlessness  with  which  these  transformations 
from  cylindrical  to  cuboid  and  from  flat  to  cylindrical, 
from  ciliated  to  non-ciliated,  recur,  one  is  tempted  to  share 
with  John  Marshall  ®  the  belief  in  a  complete  anarchy  as 
the  essence  of  cancerous  proliferation.  This  anarchy  Mar- 
shall is  inclined  to  attribute  to  the  lack  of  nerve  influence, 
no  nerves  having  as  yet  been  demonstrated  in  any  malignant 
tumor,  with  the  exception  of  a  very  few  perivascular  nerve 
fibrils.  According  to  this  view  there  would  be  no  meaning 
in  metaplasia  and  no  reversion  to  embryonal  types  or 
conditions.  The  process  would  simply  be  anarchy,  which 
might    be    subdivided  into    anarchimorphic,   anarchibolic, 

1  Friedlander,  Table  I,  No.  87. 

2  Perrone,  Table  I,  No.  257. 

3  Gougerot,  Table  I,  No.  98. 

*  Perrone. 

"  Ernst,  Table  I,  No.82. 

*  Marshall,  The  Morton  Lecture  on  Cancer  and  Cancerous  Disease,  Lancet, 
II,  1889,  pp.  1045  ff. 


PATHOLOGY    (Continued)  67 

anarchisynthetic  forms.  Beneke^  does  not  agree  with  this 
view.  According  to  him  the  nervous  system  can  only 
regulate  the  forces  contained  in  the  cell,  and  he  suggests  a 
disturbed  equilibrium  in  the  relations  and  proportions  of  the 
cell  function  as  a  causal  factor.  In  the  writer's  opinion  all 
these  facts  and  theories  lead  necessarily  to  the  conviction 
that  epithelium  is  a  highly  plastic  material,  designed  to 
accommodate  itself  in  manifold  ways  to  the  demands  which 
local,  physiological,  and  pathological  conditions  require. 
The  changes  thus  produced,  however,  can  only  take  place 
among  the  specific  epithelial  cells,  whether  derived  from 
entoderm,  ectoderm,  or  mesoderm.  The  divisions  into 
squamous,  epidermal,  cylindrical,  ciliated,  and  epithelial 
depend  upon  more  or  less  functional  and  often  unstable 
qualities  and  are  employed  more  for  the  sake  of  con- 
venience than  as  a  description  of  the  character  of  the 
cells.  The  numerous  studies  with  reference  to  the  ques- 
tion of  metaplasia  2  do  not  appear  to  give  much  enlighten- 
ment as  to  tumors,  but  seem  to  corroborate  the  opinion  here 
upheld.  The  theory  of  persisting  and  abnormally  dispersed 
germinal  centres  and  remnants,  while  it  cannot  be  dis- 
proven,  is  not  necessary  for  the  explanation  of  the  so-called 
metaplastic  transformations.^ 

1  Beneke,  Neuere  Arbeiten  zur  Lehre  vom  Carcinom,  Schmidts  Jahrbiicher, 
1892,  pp.  73  £f. 

2  Kawamura,  Beitrage  zur  Frage  der  Epithelmetaplasie,  Virch.  Arch.,  Vol. 
203,  No.  3,  1911. 

'  Fixtterer,  Uber  Epithelmetaplasie,  Lubarsch-Ostertag,  Ergebnisse,  IX, 
2,  p.  706.  Simmonds,  Munch.  Med.  Woch.,  1898,  p.  189.  Watsuji,  Zeitschr. 
f.  Krebsforschung,  Vol.  1,  No.  5,  1904. 


CHAPTER  VIII 
CLINICAL 

UNTIL  very  recently  it  was  the  conunon  consensus  of 
medical  opinion  that  the  diagnosis  of  primary  carci- 
noma or  sarcoma  of  the  lung,  if  it  could  be  made  at  all,  was 
one  of  a  more  or  less  high  degree  of  probability,  but  never 
of  certainty  and  precision.  Within  the  last  few  years,  how- 
ever, decided  advances  have  been  made  in  our  diagnostic 
methods,  rendering  it  possible  to  diagnosticate  a  timaor  of 
the  lung  with  nearly  as  much  certainty  as  the  present  status 
of  our  diagnostics  permits  a  cancer  diagnosis  for  any  other 
internal  organ  of  the  body.  Stokes's  remark,  speaking  of  the 
diagnosis  of  primary  cancer  of  the  lung,  that  "though  none 
of  the  physical  signs  of  this  disease  are,  separately  considered, 
peculiar  to  it,  yet  the  combinations  and  modes  of  succession 
are  not  seen  in  any  other  affection  of  the  lung,"^  has  been 
true  for  nearly  a  hundred  years  and  has  been  a  source  of 
stimulation  and  hope  to  many.  The  clinician's  ambition 
to-day  is  not,  at  the  conclusion  of  long  and  anxious  obser- 
vation, to  make  a  diagnosis  of  lung  tumor  that  is  merely 
probable.  His  object  should  be  to  diagnosticate  the  tumor 
at  the  earliest  possible  stage  of  its  development,  and  with 
such  accuracy  as  is  needed  for  the  basis  of  surgical  treat- 
ment.   This,  however,  is  by  no  means  an  easy  task. 

Note.  —  It  will  be  necessary  to  refer  frequently  to  the  writings  of  Stokes 
(Table  III,  No.  78),  Hughes  (Table  I,  No.  121),  Graves  (Table  III.  No.  30), 
Frankel  (Table  I,  No.  85),  Passler  (Table  I,  No.  241),  Leopold  (Table  I,  No. 
174),  and  Lenhartz  (Table  II,  No.  46),  and  to  that  most  recent  and  excellent 
pubHcation  of  Wolff  (Die  Lehre  von  der  Krebskrankheit,  Vol.  II,  Jena,  1911). 
In  making  this  general  statement  of  indebtedness,  the  writer  hopes  to  be  ex- 
cused from  special  references  to  these  authors  where  such  reference  is  deemed 
unnecessary. 

1  Diseases  of  the  Chest,  New  Sydenham  Society,  London,  1882,  pp.  420 
and  421. 

68 


CLINICAL  69 

In  many  cases  the  diagnosis  is  impossible  because  there 
are  no  symptoms  pointing  to  the  lungs  and  the  tumor  is  an 
unexpected  discovery  on  the  autopsy  table.  To  illustrate 
this,  some  cases  may  be  singled  out,  —  that  reported  by 
Colomiatti'^  and  that  of  Bernouilli.^  The  latter  was  a  case 
of  a  female  fifty-one  years  of  age,  without  chnical  history 
except  that  she  died  of  peritonitis  after  operation  for  um- 
bilical hernia.  Autopsy  was  held  the  day  after.  A  small 
round  celled  sarcoma  of  the  size  of  a  walnut  was  lodged  in 
the  right  upper  lobe  and  evidently  had  not  caused  any 
symptoms.  There  were  no  metastases,  not  even  of  a  single 
gland. 

In  some  cases  there  are  symptoms,  but  none  pointing 
toward  disease  of  the  lungs,  and  therefore  the  observer  is 
misled.  The  patient  of  Beveridge,^  it  is  true,  had  a  shght 
cough  and  some  pressure  over  the  chest,  but  not  sufficient 
to  interfere  with  his  work.  He  worked  until  death,  which 
came  suddenly  from  haemorrhage  of  the  lungs.  Kliiber  ^ 
reports  an  apparently  healthy  woman,  dying  suddenly  from 
a  bum,  without  any  lung  symptoms.  In  the  case  reported 
by  Walshe,^  there  was  no  cough,  nothing  pointing  to  the 
lungs,  but  the  symptoms  were  exclusively  psychic.  Davy's 
patient^  was  healthy  until  he  acquired  jaundice  and  pain 
in  abdomen;  physical  examination  of  lungs  was  negative, 
no  symptoms  pointing  to  lungs,  no  cough,  no  pain.  Degen^ 
reports  a  patient  healthy  and  strong;  sudden  death  from 
haemorrhage  of  lungs;  no  other  cUnical  symptoms.  The 
much  cited  case  of  McAldowie  ^  is  that  of  a  child  five  and  a 
half  months  old, — no  dyspnoea,  no  cough,  percussion  clear 
over  both  lungs. 

It  is  obvious  that  tumors  such  as  the  malignant  neoplasms 
of  the  lungs,  varying  so  widely  in  type  and  localization, 
entering  into  so  many  unstable  relations  with  other  organs 
of  the  chest  and,  through  metastases,  with  almost  every 

1  Table  II,  No.  14. 

2  tlber  primare  Lungensarkomatose,  Diss.  Miinchen,  1907. 

»  Table  I,  No.  38.  «  Table  I,  No.  56. 

*  Table  I,  No.  145.  ^  Table  I,  No.  59. 

<•  Table  I,  No.  329.  s  Table  III,  No.  53. 


70      PRIMARY  MALIGNANT  GROWTHS  OF  THE  LUNG 

organ  in  the  body,  cannot  be  expected  to  present  a  perma- 
nent and  characteristic  set  of  symptoms.  One  is  reminded 
of  Graves/  who,  reporting  a  case  of  maUgnant  disease  of  the 
lungs,  probably  sarcoma,  gives  a  minute  analysis  of  the 
cUnical  symptoms  and  shows  how  both  he  and  Stokes  were 
misled.  He  candidly  confesses  that  he  should  have  made  the 
proper  diagnosis  during  hfe,  but  adds,  in  his  characteristic 
manner,  "I  became  quite  tired  of  the  difficulty  of  attempt- 
ing to  explain  the  phenomena  observed  and  gave  up  all 
further  attempts  at  diagnosis."  It  may  be  said  in  a  general 
way  that  the  possibility  of  a  clean-cut  diagnosis  depends 
largely  upon  the  anatomical  localization  of  the  tumor  and 
upon  the  degree  of  development  which  the  disease  has 
reached  when  the  patient  is  presented.  It  is  not  probable 
that  the  actual  beginning  of  the  blastomic  development  will 
ever  be  perceived,  since  it  is  necessary  that  the  tumor 
attain  a  certain  size  before  it  can  be  recognized.  Again,  in 
the  last  stages,  the  clinical  picture  may  be  so  complicated, 
nearly  every  organ  of  the  body  participating  in  the  morbid 
process  and  causing  symptoms  which  almost  completely 
mask  the  pulmonary  lesions,  that  the  difficulties  are  greatly 
augmented  and  a  diagnosis  rendered  practically  impossible. 

There  are,  however,  certain  symptoms  which  are  common 
to  all  malignant  neoplasms  and  some  which  are  more  or 
less  peculiar  to  malignant  neoplasms  of  the  lungs,  to  which 
brief  attention  must  be  given. 

I.  Pain.  This  is  frequently  not  a  real,  acute  pain,  but 
rather  a  sense  of  discomfort  and  pressure  in  the  chest. 
According  to  Schmidt  ^  the  pulmonary  parenchyma  is  prob- 
ably insensible  to  pain,  therefore  the  acute  or  chronic 
genuine  stabbing  pain  is  brought  about  when  the  pleura 
participates  in  the  inflammatory  processes  which  are  apt 
to  accompany  the  progress  of  the  disease.  Taking  into 
account  the  well-known  relations  between  the  two  folds  of 
the  pleura  and  the  nerves,  —  the  brachial  plexus,  intercostal 
nerves,  phrenic  nerve,  —  and  the  diaphragm,  it  is  clear  that 

1  Table  III,  No.  30. 

*  Die  Schmerzphenomene  bei  inneren  Krankheiten,  etc.,  Wien,  1906. 


CLINICAL  71 

the  pain  produced  in  one  place  may  be  referred  to  localities 
quite  distant  from  the  point  of  origin.  The  pain  in  the 
shoulder  and  around  the  clavicle,  the  neuralgias  of  the  arm, 
the  intercostal  pains  along  the  chest  and  in  the  abdomen 
and  diaphragm,  which  so  often  occur  both  in  carcinoma  and 
in  sarcoma,  are  thus  easily  explained,  and  it  is  understood 
that  where  there  is  no  pain  the  pleura  has  evidently  not 
been  involved.  Schmidt  also  points  out  that  a  large  area 
of  dulness,  without  spontaneous  or  pressure  pain,  excludes 
any  inflammatory  process  of  either  fold  of  the  pleura  and 
suggests  the  possibility  of  a  neoplasm.  Figures  represent- 
ing an  approximate  estimate  of  the  occurrence  of  pain  in 
malignant  lung  tumors  can  be  obtained  from  Tables  I  and  II. 
In  Table  I  pain  is  not  mentioned  in  206  cases  out  of  374. 
This,  of  course,  does  not  mean  that  pain  was  not  present, 
but  merely  that  any  reference  to  pain  was  omitted.  The 
probability  therefore  is  that  the  cases  in  which  pain  was  a  fea- 
ture are  much  more  numerous  than  would  appear  from  the 
Table.  In  eighteen  cases  it  is  distinctly  stated  that  there 
was  no  pain  during  the  entire  course  of  the  disease,  while  pain 
is  mentioned  as  present  in  one  hundred  and  fifty  cases.  In 
Table  II,  dealing  with  sarcoma,  pain  is  given  as  a  symptom 
at  some  time  during  the  disease  in  fifty-two  cases,  in  two 
cases  only  is  it  distinctly  stated  that  there  was  no  pain 
whatever,  in  six  cases  there  is  no  clinical  history,  and  pain 
is  not  mentioned  in  the  history  of  thirty-four  cases. 

The  possible  irradiations  along  various  nerve  tracts  are 
illustrated  by  the  case  of  Demange,^  in  which  the  pain  was 
constantly  referred  to  the  healthy  side.  In  two  cases  the 
pain  was  mostly  abdominal,  while  in  the  case  of  Harris  ^ 
the  pain  was  referred  to  both  sides  of  the  chest.  If  one 
could  draw  deductions  from  these  figures,  it  would  seem  that 
sarcoma  causes  more  pain  than  carcinoma.  This  result, 
however,  is  probably  illusory  and  caused  by  the  imperfect 
statistics. 

11.  Cough.  This  complication  is  one  that  would  natu- 
rally be  expected  in  any  malady  of  the  lungs,  and  therefore 

1  Table  II,  No.  17.  ^  Table  II,  No.  33. 


72      PRIMARY  MALIGNANT  GROWTHS  OF  THE  LUNG 

in  tumors  of  the  lung.  Indeed,  cough  is  probably  the  most 
common  of  all  symptoms  appertaining  to  lung  tumors,  and 
there  are  but  few  cases  in  which  it  is  not  a  factor.  A  rather 
insignificant,  but  fairly  constant,  irritating  cough,  mostly 
without  expectoration,  may  be  the  earliest  symptom  of 
tumor.  Where  this  cough  exists  and  nothing  abnormal  is 
found  in  the  chest,  the  upper  air-passages,  oesophagus,  etc., 
the  possibility  of  the  presence  of  a  lung  tumor  should,  in  the 
writer's  opinion,  suggest  itself.  A  case  observed  by  the 
writer,  which  does  not  appear  among  the  material  collected, 
may  serve  to  illustrate  this  rather  important  point.  It  con- 
cerned a  lady  of  some  sixty-odd  years,  fairly  healthy,  and  so 
far  as  known,  without  any  hereditary  strain  of  malignancy. 
She  began  to  cough  this  same  short,  hacking  cough,  without 
pain,  without  expectoration.  Both  lungs  on  close  examina- 
tion gave  no  indication  of  anything  abnormal  and  nothing 
abnormal  could  be  detected  anywhere,  except  a  trifling 
pharyngitis.  Very  gradually  some  loss  of  flesh  and  strength 
became  apparent,  and  after  several  months  a  very  small 
area  of  dulness  at  the  right  hilus,  together  with  some  fairly 
loud  cornage,  could  be  made  out.  The  dulness  gradually 
extended.  For  some  time  previous  a  tumor  had  been  sus- 
pected, principally  from  the  cornage,  and  the  diagnosis  was 
corroborated  when  the  dulness  and  cornage  were  also  found 
at  the  apex.  There  was  never  much  expectoration,  and  no 
blood.  The  emaciation  and  weakness  increased,  the  area 
of  dulness  on  the  right  lung  extended  over  the  entire  lower 
and  middle  lobes,  with  diminished  voice  and  breathing, 
secondary  plainly  palpable  nodules  appeared,  especially  in 
the  hver,  accompanied  by  jaundice,  and  death  from  exhaus- 
tion took  place  in  about  a  year  from  the  beginning  of  the 
cough.  No  autopsy  could  be  obtained,  but  there  is  httle 
room  for  doubt  that  this  was  a  genuine  case  of  carcinoma 
of  the  lung. 

Besides  this  slight  hacking  cough,  accompanied  by  little  or 
no  distress,  all  varieties  of  cough,  up  to  the  most  violent, 
explosive,  and  harassing  forms,  are  reported.  The  cough 
may,  as  just  mentioned,  be  an  early  symptom  of  the  disease; 


CLINICAL  73 

on  the  other  hand  there  may  be  no  cough  until  shortly 
before  the  fatal  end.  As  bronchitis  is  one  of  the  ordinary 
features  of  the  case,  the  fairly  loose  cough,  accompanied 
by  large  and  small  mucoid  rales,  is  present  in  the  majority  of 
cases.  If  bronchiectatic  cavities,  or  cavities  of  other  origin, 
are  present,  there  will  probably  be  attacks  of  coughing  of 
an  explosive  character,  discharging  large  quantities  of  muco- 
purulent or  purely  purulent  expectoration,  often  mixed  with 
blood.  When  the  cavities  are  sufficiently  refilled  or  com- 
munication with  the  bronchus  is  again  restored,  these  spells 
are  apt  to  recur.  The  distressing,  rasping,  but  usually  dry 
cough  that  is  caused  by  compression  or  irritation  of  the 
larger  bronchi  and  the  trachea  is  often  noted.  At  times  this 
cough  is  accompanied  by  considerable  stridor.  Schwalbe  ^ 
claims  that  carcinoma  produces  very  little  stridor,  if  any  at 
all,  but  that  it  occurs  in  its  greatest  intensity  and  most 
frequently  in  sarcoma,  and  his  explanation  of  this  is  that 
sarcoma  gives  rise  to  earlier  and  more  extensive  involvement 
of  the  mediastinal  organs  than  carcinoma,  thereby  exerting 
more  pressure  on  the  trachea  and  nerves.  This  does  not, 
perhaps,  quite  correspond  with  the  actual  facts,  and  it  can 
be  seen  from  the  material  collected  here  that  carcinoma  also 
can,  and  frequently  does,  involve  all  the  mediastinal  organs. 
There  is,  furthermore,  the  hoarseness,  also  the  well-known 
laryngeal  cough,  both  of  which  usually  occur  in  late  stages 
of  the  disease,  when  either  one  or  both  superior  larjmgeal 
recurrent  nerves  have  become  involved  and  paralyzed.  In 
Table  I  cough  in  its  various  forms  is  mentioned  in  174  cases, 
while  in  191  cases  it  is  not  mentioned.  In  nine  cases  it  is 
distinctly  stated  that  there  was  no  cough.  In  Table  II  cough 
is  mentioned  as  a  symptom  forty-six  times;  five  cases  had  no 
cough,  and  thirty-nine  passed  without  any  mention  of  it. 

III.  Sputum.  Much  more  important  than  the  cough, — 
in  fact,  one  of  the  principal  signs  to  be  depended  upon  for 
the  diagnosis  of  malignant  lung  tumors, — is  the  character 
of  the  sputum.  This,  however,  can  only  be  satisfactory  as 
the  result  of  close  study.    It  is  necessary  to  bear  in  mind  that 

1  Deut.  Med.  Woch.,  1891,  No.  45. 


74     PRIMARY  MALIGNANT  GROWTHS  OF  THE  LUNG 

a  single  examination  of  the  sputum  will  rarely  give  reliable 
results.  The  ordinary  routine  examination  of  the  expecto- 
ration, such  as  is  the  common  practice,  which  consists  in  a 
search  for  tubercle  bacilh  or  elastic  fibres,  and  at  best  a 
few  cells,  is  entirely  insufficient  when  so  delicate  a  diagnosis 
as  that  of  primary  lung  tumor  is  the  object.  It  is  necessary 
to  examine  the  sputa  systematically  and  thoroughly,  both 
morphologically  and  bacteriologically,  and  under  certain 
conditions  even  chemically,  as  frequently  as  possible,  until 
the  diagnosis  is  assured.  In  Table  I  there  are  143  instances 
out  of  374  in  which  no  mention  is  made  of  the  sputum.  It 
is,  therefore,  not  ascertainable  whether  in  these  cases  there 
was  any  expectoration  or  what  its  character  may  have  been 
if  present.  In  thirty-six  cases  it  is  clearly  stated  that  there 
was  no  expectoration.  Stokes^  was  the  first  to  speak  of  a 
pecuharly  homogeneous  and  tenacious  sputum,  the  color  of 
which  he  compared  to  black  currant  jelly  and  which  is 
spoken  of  by  others  as  resembUng  raspberry  jelly  or 
prune  juice.  The  latter  designation  is  particularly  used  in 
American  textbooks.  Stokes  considered  this  sputum  as 
pathognomonic  of  lung  tumor,  especially  of  carcinoma, 
and  many  textbooks  still  spread  this  behef.  It  has  been 
shown,  however,  that  this  peculiar  sputum  is  per  se  not 
pathognomonic  for  malignant  tumors  of  the  lung.  It  occurs 
in  other  diseases,  and  even  in  primary  carcinoma  of  the 
lungs  it  is  not  constant  and  is  recorded  in  but  few  cases. 
Looking  over  Table  I,  it  is  foimd  that  the  currant,  rasp- 
berry, and  prune  juice  sputa  have  been  placed  on  record 
in  only  six  out  of  the  374  cases.  This  may  not  absolutely 
coincide  with  the  actual  facts,  but  it  is  reasonable  to  suppose 
that  where  there  is  a  clinical  history  given,  so  characteristic 
a  symptom  would  be  mentioned.  In  Table  II  only  two  cases 
are  recorded  out  of  a  total  of  ninety.  But  though  this  kind 
of  sputum  cannot  be  considered  pathognomonic,  it  should, 
in  the  writer's  opinion,  if  associated  with  other  symptoms 
that  all  point  toward  tumor  of  the  lung,  be  considered 
corroborative  of  the  diagnosis.     The  processes  ultimately 

^  Loc.  cit. 


CLINICAL  75 

at  work  in  the  production  of  this  peculiar  type  of  sputum 
are  entirely  unknown  up  to  date.  It  seems  certain  that  the 
peculiar  color  is  not  merely  due  to  the  presence  of  blood; 
there  must  be  other  conditions  involved.  Perhaps  it  is 
not  unreasonable  to  suspect  that  some  specific  kind  of 
haemolysis,  caused,  it  may  be,  by  some  toxic  product  of  the 
tumor,  formed  only  under  certain  conditions  (perhaps  oleic 
acid  —  conf.  Faust  0  is  responsible.  The  subject  has  been 
insufficiently  studied  and  is  well  worth  further  research. 

Bloody  expectoration  is  associated  with  most  cases  of  lung 
tumors  at  some  period  of  their  development.  The  sputum, 
either  mucoid  or  mucopurulent,  as  the  case  may  be,  may 
be  intimately  mixed  with  the  blood,  or  the  latter  may 
appear  in  the  form  of  haemoptysis,  varying  in  profuseness. 
It  has  been  claimed  ^  that  haemoptysis  is  uncommon  in  lung 
tumors.  According  to  the  writer's  own  experience  and 
his  study  of  the  hterature  of  the  subject,  which  is  to  a  great 
measure  collected  in  the  Tables,  this  statement  cannot  be 
verified.  It  seems,  on  the  contrary,  that  haemoptysis  is  of 
rather  frequent  occurrence.  A  number  of  cases  are  reported 
in  which  the  very  first  symptom  was  a  profuse  haemoptysis, 
others  where  haemoptysis  occurred  frequently  in  the  course 
of  the  sickness,  and  in  quite  a  number  of  cases,  sev- 
eral of  them  under  the  writer's  own  observation,  death 
was  caused  by  very  profuse  haemorrhage.  The  mere 
bloody  sputum,  too,  may  appear  as  one  of  the  very 
first  symptoms,  though  it  sometimes  requires  all  the  skill 
of  a  trained  cross-examiner  to  elicit  the  fact  that  there  has 
at  one  time  been  some  slight  bloody  expectoration.  On 
the  other  hand,  blood  may  appear  at  a  later  stage,  or  even 
at  the  very  last  stage,  and  sometimes,  again,  be  constantly 
present  throughout  the  course  of  the  disease.  The  records 
in  Table  I  show  about  one  hundred  cases  in  which  the 
sputum  was  bloody,  not  counting  the  currant,  raspberry, 
and  prune  juice  sputa  mentioned  before,  and  not  counting 

^  'Ober  chronische  Olsaurevergiftung,  Archiv.  f .  exp.  Path,  und  Phar. 
Festschrift  f.  Schmiedeberg,  p.  171. 

2  West,  Table  I,  No.  326.  Also  Hampeln,  €ber  den  Auswurf  bei  Lungen- 
carcinom,  Z'tschrift  f.  klin.  Med.,  Vol.  32,  1897,  p.  246. 


76     PRIMARY  MALIGNANT  GROWTHS  OF  THE  LUNG 

sixteen  cases  of  profuse  haemoptysis.  In  sixty-five  of  these 
one  hundred  cases  pure  blood  seems  to  have  been  expecto- 
rated, representing,  as  it  were,  small  hsemoptyses.  The 
others  were  various  kinds  of  sputa,  —  mucoid,  mucopuru- 
lent, purely  purulent,  etc.,  —  all  of  them  mixed  more  or 
less  with  blood.  In  three  cases  tubercle  bacilli  were  found 
in  the  bloody  expectoration.  In  thirteen  cases  the  sputa 
were  entirely  free  from  blood.  In  forty-five  cases  the 
expectoration  was  ordinarily  without  blood,  and  character- 
istic merely  of  the  condition  of  the  bronchi  and  the  lungs, 
without  reference  to  tumor.  Greenish  expectoration  is 
mentioned  twice,  and  one  case  is  reported  of  olive-green 
sputum.^  Just  what  kind  of  sputa  these  are  cannot  be 
ascertained,  as  there  was  no  detailed  examination  recorded. 
They  are  probably  not  characteristic.  In  Table  II  sputum 
is  not  mentioned  in  thirty-one  cases,  in  eight  cases  no 
expectoration  took  place,  in  ten  others  there  was  not  even 
a  cough,  while  twenty-five  were  bloody,  three  with  profuse 
hsemoptyses.  In  twelve  cases  haemoptysis  is  the  main  charac- 
teristic of  the  sputum.  Green  sputum  is  noted  five  times, 
and  it  is  believed  that  Bell  ^  was  the  first  to  mention  it  as 
occurring  in  sarcoma.  There  are  no  means  of  judging  of 
its  character  or  its  relation  to  sarcoma.  In  Janssen's  case^ 
the  sputum  was  not  merely  green,  but  grass-green,  and  he 
believes  this  to  be  characteristic  of  sarcoma  of  the  lung. 
Traube  ^  finds  grass-green  sputa  associated  with  pneumonia 
or  bronchitis,  accompanied  by  jaundice,  —  the  so-called 
''bilious  pneumonia,"  —  and  also  in  chronic  pneumonia 
without  icterus.  He  claims  that  the  varying  colors  of  these 
sputa  are  due  to  the  red  blood  cells  and  the  hsematin  going 
through  the  same  cycle  of  discolorations  as  an  ordinary 
haemorrhage  into  the  skin,  the  last  being  green  and  repre- 
senting, according  to  Traube,  the  last  stages  of  oxidation  of 
the  haematin.  He  does  not  mention  tumor. 
That  grass-green  sputum  cannot  be  characteristic  of  sar- 

1  Elliott,  Table  III,  No.  24. 

»  Table  II,  No.  3. 

3  Table  II,  No.  39. 

*  Gesammelte  Beitrage  f.  Path.  u.  Phys.,  Vol.  II,  1871,  p.  699. 


CLINICAL  77 

coma  of  the  lungs  may  be  deduced  from  the  fact  that  it  does 
not  appear  in  the  majority  of  cases,  while  sputum,  mentioned 
as  merely  green,  is  seen  in  carcinoma,  as  well  as  in  other 
diseases  of  the  lungs  and  bronchi.  Moreover,  grass-green 
sputum  is  said  to  occur  rather  frequently  in  cases  of  chronic 
pneumonia  and  of  pulmonary  abscess.  Here,  also,  further 
study  is  imperative,  not  only  to  determine  the  diagnostic 
value,  but  also  the  conditions  under  which  such  peculiar 
sputa  are  produced.  Perhaps  there  is  some  special  conjunc- 
tion of  circumstances  in  cases  of  sarcoma  of  the  lung  which, 
while  not  occurring  very  frequently,  produces  when  present 
this  peculiarly  characteristic  sputum.  The  writer  feels  that 
in  a  case  of  suspected  sarcoma  of  the  lungs  the  grass-green 
sputiun  of  Janssen  would  be  strong  corroborative  evidence. 
It  seems  at  first  glance  almost  self-evident  that  sputa  from 
a  malignant  growth  of  lungs  and  bronchi  must  necessarily 
contain  tumor  elements,  and  that  thus  the  diagnosis  of  such 
tumors  could  easily  be  made  certain  beyond  doubt.  Some 
reflection  will  show,  however,  that  this  is  not  so  simple  as  it 
seems,  and  must  in  fact  be  a  rather  rare  occurrence.  There 
are  first  to  be  considered  the  quantities  of  various  kinds  of 
epithelial  cells  that  can  normally  be  present  in  the  mouth 
and  air-passages;  the  cylindrical  cells,  ciliated  and  without 
cilia,  that  come  from  the  bronchi,  the  nose,  etc.,  the  possible 
admixture  of  cells  from  the  oesophagus,  etc.,  all  of  which 
would  prevent  the  direct  recognition  of  tumor  cells.  It  is, 
therefore,  always  hazardous  to  suspect  lung  tumor  merely 
from  the  presence  of  scattered  epithelial  or  round  cells.  On 
the  other  hand,  if  the  cells  in  question  occur  in  unusually 
large  quantities  and  more  or  less  constantly,  or  if  cells  which 
normally  are  not  found  in  the  expectoration  are  constantly 
present,  the  suspicion  of  tumor  is  permissible,  provided  the 
clinical  symptoms  correspond.  The  tumor  elements  are 
not  apt  to  be  expectorated  unless  there  is  open  communica- 
tion with  a  bronchus  and  the  tumor  itself  has  softened  and 
is  in  a  state  of  incipient  disintegration.  Tumor  cells,  also, 
that  are  expectorated  under  such  circumstances  are  as  a 
rule  in  such  a  state  of  degeneration  that  their  character  as 


78     PRIMARY  MALIGNANT  GROWTHS  OF  THE  LUNG 

derivatives  of  a  neoplasm  can  only  be  recognized  if  some 
remnants  of  their  blastomic  structm-e  and  organization 
remain.  This,  of  com"se,  would  make  the  diagnosis  abso- 
lutely certain,  especially  as  secondary  lung  tumors  seldom 
cause  marked  symptoms,  and  never  such  as  are  peculiar  to 
primary  growths.  Some  cases  in  point  are  on  record.  It 
has  even  happened  that  a  portion  of  necrosed  lung  tissue  has 
been  expectorated  before  any  other  symptoms  of  pulmonary 
disease  were  apparent,  as  in  the  case  of  Claisse.^  In  the 
case  of  Ehrich,2  villous  and  bloody  masses  containing  can- 
cerous material  were  expectorated.  Pearson^  records  a  case 
in  which  pieces  of  necrosed  lung  tissue  were  coughed  up, 
accompanied  by  tubercle  bacilli,  and  the  tumor  was  diagnos- 
ticated by  him  as  ''encephaloid."  A  similar  case  was  that 
of  Turnbull  and  Worthington,^  in  which  a  lump  the  size  of 
a  walnut,  of  alveolar  structure  and  containing  cylindrical  and 
cuboidal  ceUs,  was  expectorated.  Still  another,  was  the  case 
recorded  by  Peacock,^  in  which  masses  were  expectorated 
consisting  of  spindle  and  round  cells.  There  are  a  number  of 
other  cases  which  can  be  found  by  reference  to  the  Tables, 
most  of  which  are  doubtful,  however,  because  they  lack  the 
all-important  microscopic  examination.  Most  of  the  cases 
in  which  the  expectoration  is  recorded  of  larger  or  smaller 
portions  of  tumor,  which  are  degenerated  but  nevertheless 
distinctly  recognizable  as  either  carcinoma  or  sarcoma, 
belong  as  a  rule  to  late  stages,  and  while  they  clinch  the 
diagnosis  they  do  so  at  a  time  when  all  hope  of  beneficial 
therapeutic  interference  is  practically  gone.  It  is  quite 
natural  therefore  that  anxious  search  is  made  for  elements 
whose  appearance  in  the  sputum,  while  characteristic  of  lung 
tumors,  is  not  delayed  until  the  later  stages  of  development. 
Hampeln  ^  found  certain  cells  in  the  expectoration  from  cases 
of  carcinoma  of  the  lungs  which,  according  to  him,  if  only 

^  Table  I,  No.  52.  In  the  discussion  of  this  case,  Troisier  reports  a  case  of 
primary  cancer  of  the  lung  in  which  the  diagnosis  was  confirmed  by  tumor 
particles  in  the  sputum.     Menetrier  also  reports  similar  cases. 

2  Table  I,  No.  78.  ^  Table  III,  No.  59. 

3  Table  I,  No.  249.  e  Loc.  cit. 
«  Table  I,  No.  321. 


CLINICAL  79 

seen  but  a  single  time,  assure  the  diagnosis  of  carcinoma. 
He  says,  '^  Polymorphic,  polygonal  cells  that  are  entirely 
free  from  pigmentation  are  seen  in  the  sputum  where  there  is 
carcinoma  of  the  lungs,  and  in  no  other  case  but  carcinoma. 
In  all  other  cases,  if  there  are  epithelial  cells  at  all  in  the 
sputa,  they  are  principally  round  or  oval  cells,  pavement  or 
ciliated  cells,  highly  pigmented."  These  cells  do  not  seem 
to  have  gained  favor  in  the  eyes  of  diagnosticians.  The 
writer  is  not  aware  that  Hampeln's  views  have  been  corrob- 
orated by  others,  and  he  himseK  has  never  seen  the  cells  in 
question.  He  must  confess,  however,  that  his  examinations 
with  reference  to  them  have  not  been  sufficient  to  warrant 
a  definite  conclusion.  Lenhartz^  finds  large  spherical  cells 
filled  with  a  multitude  of  fatty  granules  and  associated  with 
abundance  of  epithelial  cells  that  are  strangely  deformed 
and  possess  club-like  or  tail-like  projections.  He  is  of  opinion 
that  these  fatty  or  granular  cells  are  pathognomonic  of  pul- 
monary carcinoma.  Tuberculosis  may  be  present  without 
changing  anything  in  the  character  and  diagnostic  value  of 
these  cells.  In  Table  I  the  granular  fatty  cells  are  found  in 
the  sputum  seven  times.  The  writer  is  inclined  to  agree 
with  Lenhartz  that  these  cells  are  strictly  pathognomonic, 
at  least  of  carcinoma  of  the  lung,  there  being  as  yet  insuf- 
ficient experience  as  to  sarcoma.  Since  the  writer's  attention 
was  drawn  to  these  cells  he  has  found  them  in  every  case 
of  primary  carcinoma  that  has  come  under  his  observation 
(about  twelve  cases),  and  a  very  long  and  close  study  of  sputa 
from  all  manner  of  other  lung  diseases  tends  to  show  that 
they  occur  in  carcinoma  alone.  The  technique  of  examina- 
tion is  very  simple,  inasmuch  as  no  staining  is  required, 
and  a  spread  of  sputum,  not  too  thin,  perhaps  in  a  little 
glycerine  and  water,  or  perhaps  without  any  addition,  if 
examined  carefully  with  a  moderate  magnification,  will  not 
fail  to  show  these  ''Kornchenzellen"  if  they  are  present. 
The  cells  can  sometimes  be  obtained,  also,  by  puncture  of 
the  pleura  or  the  tumor. 2    It  is  to  be  remembered  that  the 

1  Miinch.  Med.  Woch.,  1898,  No.  1,  p.  28. 

2  Muser,  Table  I,  No.  209. 


80     PRIMARY  MALIGNANT  GROWTHS  OF  THE  LUNG 

conditions  under  which  these  cells  are  formed  are  still  un- 
known. Lenhartz  believes  that  they  are  produced  by  fatty 
degeneration  of  the  large  epithelial  cells  of  the  tumor.  This, 
however,  is  merely  hypothesis.  Their  appearance  in  the 
sputum,  —  for  what  reason  is  not  known,  —  is,  moreover, 
very  inconstant  and  irregular.  It  may  be  necessary  to  hunt 
for  them  for  days  in  succession  before  they  are  found;  it  may 
be,  on  the  other  hand,  that  the  first  examination  will  show 
them.  They  may  occur  in  great  profusion,  or  again  only 
scattered  singly  here  and  there  through  the  smear.  But  it 
is  the  writer's  conviction  that  when  found  they  are  pathog- 
nomonic of  pulmonary  carcinoma,  and  furthermore  that  a 
daily,  systematic  examination  of  the  sputum  is  necessary 
and  that  one  should  not  be  discouraged  if  the  cells  are  not 
found  at  once. 

IV.  That  respiratory  difficulties  constitute  one  of 
the  most  frequent  symptoms  in  lung  tumors  is  obvious.  An 
insignificant  shortness  of  breath  on  slight  exertion  is  fre- 
quently reported  as  the  first  symptom.  This  may  be  present 
long  before  percussion  and  auscultation  give  evidence  of 
any  lesion  in  the  lungs.  The  difficulty  in  breathing  is 
often  so  slight  that  only  a  rigid  inquiry  will  elicit  the  fact  of 
its  existence.  Its  gradual  increase  may  be  the  first  thing 
to  alarm  the  patient  and  cause  him  to  submit  to  a  medi- 
cal examination.  Beginning  with  this  slightest  form  of 
dyspnoea,  all  transitions  up  to  the  severest  orthopncea  occur. 
Among  the  material  here  collected,  numerous  examples 
will  be  found  of  death  from  suffocation.  No  physician 
who  has  ever  seen  the  intolerable  and  hopeless  suffering  of 
those  unfortunates  who  are  doomed  to  the  awful  death  by 
suffocation  accompanied  by  intensest  orthopnoea  extending 
over  weeks,  sometimes  even  months,  will  ever  forget  it. 
Fortunately,  it  is  not  always  continuous,  but  is  apt  to  come 
in  spells.  Nevertheless,  it  is  one  of  the  most  cruel  tortures 
to  which  man  can  be  subjected  and  before  which  the  physi- 
cian has  stood  powerless.  Not  only  is  he  unable  to  cure, 
but  even  to  relieve,  as  morphine  loses  its  virtue  and  surgery 
is  helpless.     Complete  closure  of  a  bronchus  does  not  cause 


CLINICAL  81 

these  worst  forms  of  suffocation,  but  at  most  only  a  very 
moderate  degree  of  dyspnoea  following  exertion.  The  in- 
tensest  forms  are  brought  about  mainly  by  compression  or 
obstruction  of  the  trachea.  The  tumor  may  grow  up  from 
below  through  a  main  bronchus  into  the  trachea  and  thus 
obstruct  it,  or,  as  is  perhaps  more  frequently  the  case,  in- 
volvement of  the  mediastinal  glands  may  form  large  masses 
pressing  upon  the  trachea  from  without  so  as  to  produce 
almost  entire  closure.  Though  a  most  frequent  symptom, 
dyspnoea  does  not  necessarily  complicate  lung  tumors.  In 
Table  I  there  is  a  record  of  twenty  cases  in  which  no  dyspnoea 
of  any  kind  was  found  throughout  the  disease.  There  are 
189  cases  where  dyspnoea  is  not  mentioned.  In  165  instances 
dyspnoea  was  present,  and  this  number  includes  all  the  differ- 
ent forms  of  respiratory  disturbance,  from  the  slightest  incip- 
ient dyspnoea  to  the  most  terrific  orthopnoea.  In  Table  II 
appear  two  cases  in  which  it  is  recorded  that  no  dyspnoea 
was  present,  fifty-two  cases  in  which  dyspnoea  is  recorded 
as  present  at  some  stage  of  the  disease,  leaving  thirty-six 
cases  in  which  no  mention  is  made  of  this  symptom. 

V.  Cachexia,  the  usual  companion  of  malignancy,  is 
also  a  very  frequent  accompaniment  of  lung  tumors.  Its 
incidence,  however,  is  extremely  irregular.  There  are  cases 
on  record,  as  the  Tables  show,  in  which  loss  of  flesh  and 
weight  are  apparently  among  the  earliest  symptoms,  cer- 
tainly before  anything  abnormal  could  be  detected  on  the 
lungs. ^  In  other  cases  there  is  no  apparent  loss  in  flesh  and 
weight  throughout  the  course  of  the  disease.  In  one  of  the 
writer's  own  cases,^  though  there  were  profuse  haemorrhages 
and  the  disease  lasted  about  four  years,  the  man  kept  stout 
and  florid  and  apparently  without  any  loss  of  strength  until 
his  death,  which  was  caused  by  suffocation  from  a  profuse 
and  sudden  haemorrhage.  A  positive  gain  in  weight  during 
the  progress  of  the  disease  has  been  observed  by  v.  Fetzer' 

1  Rottman,  Table  I,  No.  277. 

2  Table  I,  No.  3. 

'  Bronchuscarcinom,  Correspondenzblatt  Wiirtemberg  artzlicher  Landes- 
verein,  Feb.  25,  1905. 
7 


82     PRIMARY  MALIGNANT  GROWTHS  OF  THE  LUNG 

and  also  by  Rothman.^  Le  Sourd  ^  reports  a  distinct  ten- 
dency to  obesity  throughout  the  disease.  Notwithstanding 
all  that,  a  great  number  of  cases  are  recorded  in  which  death 
ensued  from  exhaustion. 

VI.  There  is  still  considerable  diversity  of  opinion  as  to 
fever  in  carcinoma  and  sarcoma  of  the  lungs.  Kast^  and 
Ebstein  and  others  recognize  a  somewhat  typical  intermit- 
tent, but  usually  not  very  high,  fever  in  the  course  of  the 
growth  of  sarcoma.  DaroUes  ^  is  of  opinion  that  there  is  no 
fever  in  uncomplicated  cases  of  carcinoma  of  the  lungs.  On 
the  other  hand  Hampeln  ^  finds  an  intermittent  fever  similar 
to  the  malarial  type  in  cases  of  occult  visceral  carcinoma. 
The  same  is  maintained  by  Kast^  and  a  number  of  others, 
who  also  find  fever  of  an  intermittent  character,  especially 
in  cases  of  cancer  of  the  stomach.  Without  going  into  the 
details  of  this  subject  for  carcinoma  in  general,  but  consid- 
ering only  the  carcinoma  of  the  lungs,  it  appears,  looking  over 
the  list  of  cases,  that  such  as  seem  to  be  uncomplicated  have, 
as  a  rule,  no  rise  of  temperature  of  any  significance.  That 
fever  in  an  absolutely  uncomplicated  case  of  cancer  of  the 
lungs  is  possible,  cannot  be  denied,  in  view  of  the  modern 
researches  on  auto-intoxications  and  metabolic  disturbances 
caused  by  the  carcinoma  itself.  In  the  case  of  cancer  of  the 
lungs,  however,  it  is  hardly  possible  to  determine  whether 
the  tumor  is  uncomplicated  or  not,  and  in  the  overwhelming 
majority  of  cases  it  will  probably  be  sufficiently  complicated 
by  bronchitis,  inflammatory  conditions  of  the  lung  tissue, 
bronchiectatic  dilatations,  etc.,  to  account  for  whatever 
temperatures  may  occur. 

VII.  Difference  in  pulse  in  the  two  radials  has  fre- 
quently been  reported.  This  is  easily  explained  by  the  tumor 
pressing  upon  one  or  the  other  of  the  subclavian  arteries. 

1  Table  I,  No.  275. 
»  Table  I,  No.  179. 
'  Jahrbuch  der  Hamburger  Staatsanstalten,  1889,  I. 

*  Du  cancer  pleuro-pulmonaire  au  point  de  vue  clinique.    These,  Paris,  1877. 
»Z't8chrift  f.  klin.  Med.,  1884,  Vol.  8,  p.  221;   and  1888,  Vol.  14,  p.  566, 

Zur  Symptomatologie  okkulter  visceraler  Karzinome. 

•  Loc.  cit. 


CLINICAL  83 

Japha^  reports  a  distinct  bradycardia  in  one  of  his  cases, 
but  no  cause  for  it  is  mentioned.  So  far  as  one  can  see 
from  the  clinical  and  post-mortem  notes,  it  does  not  seem 
to  have  any  connection  with  the  lung  tumor. 

VIII.  The  blood  count  has  not  thus  far  been  of  much 
assistance  in  the  diagnosis  of  lung  tumors.  There  are  but 
a  few  cases  in  which  the  blood  count  is  reported, — in  all 
less  than  a  dozen,  —  and  even  these  lose  greatly  in  value 
inasmuch  as  it  does  not  appear  from  the  records  how  the 
haemoglobin  was  estimated  and  how  often  and  under  what 
varying  conditions  the  blood  count  was  done.  One  almost 
involuntarily  gets  the  impression  that  the  blood  count  was 
done  only  once,  while  it  is  obvious  that  it  should  be  repeated 
at  stated  intervals.  Here  also  is  a  fruitful  field  for  further 
investigation. 

Of  the  few  blood  counts  that  are  on  record,  it  may 
be  well  to  mention,  first,  that  of  Kappis.^  He  finds 
cancer  cells  with  mitosis  in  the  sputum.  The  blood  he 
reports  as  follows:  Hb.,  120;  red  cells,  6,200,000;  white 
cells,  50,560-40,700;  eosinophiles,  33-39^-12%;  polynu- 
clears,  56.9%.  The  pleuritic  effusion  was  a  sanguinolent 
serum  which  contained  no  eosinophiles.  In  this  case  the 
blood  count  appears  to  have  been  taken  repeatedly,  but  is 
thus  far  inexplicable  in  that  there  is  nothing  in  the  history 
as  given  by  the  author  to  explain  the  enormous  leucocytosis, 
the  accompanying  polycythsemia,  and  the  very  high  per- 
centage of  eosinophiles,  the  polynuclears,  at  the  same  time, 
being  rather  low.  The  autopsy  also  throws  no  light  upon 
this  curious  condition.  The  author  remarks  in  his  descrip- 
tion of  the  microscopical  structure  that  enormous  heaps  of 
eosinophiles  were  found  in  places  free  from  tumor.  It  is 
best  in  this  case  to  indulge  in  no  hypotheses  as  to  the  possible 
cause  of  this  blood  picture  and  its  contradictions. 

Another  imperfect  blood  count  is  given  by  Naun^:  Hb.,  40; 
leucocytes,  15,000.  It  is  to  be  regretted  that  the  number 
of  erythrocytes  is  not  stated,  because  without  knowing  the 
number  of  red  cells  one  is  left  in  doubt  whether  this  is  a 

1  Table  I,  No.  136.  »  Table  I,  No.  139.  '  Table  I,  No.  224. 


84     PRIMARY  MALIGNANT  GROWTHS  OF  THE  LUNG 

mere  haemoglobin  anaemia  with  a  moderate  leucocytosis, 
or  whether  the  red  cells  also  are  diminished.  A  complete 
blood  count,  including  differential,  and  repeated  several 
times  during  the  course  of  the  disease,  should  in  the  future 
be  considered  an  essential  requirement.  In  a  similar  way 
Musser^  records  merely  increased  leucocytosis,  without  fur- 
ther details,  in  both  his  cases.  In  two  of  the  writer's  own 
cases, 2  where  the  advantages  of  hospital  observation  could  be 
had,  the  blood  count  was  taken  repeatedly  with  the  average, 
in  Case  No.  2,  of:  Hb.,  65;  red  cells,  4,500,000;  leuco- 
cytes, 15,000.  This  corresponds  very  nearly  with  the  blood 
count  given  by  Cohen  and  Kirkbride^:  Hb.,  60;  red  cells, 
4,400,000;  leucocytes,  18,000;  differential  count  of  leucocytes 
not  stated.  In  Case  No.  4  the  blood  count  was  as  follows: 
Hb.,  62;  red  cells,  3,980,000;  leucocytes,  14,300;  differen- 
tial fairly  normal.  In  this  case,  besides  the  haemoglobin 
anaemia,  there  is  a  distinct  reduction  in  the  number  of  red 
cells,  but  no  deformation  or  other  alterations  in  them. 

The  case  of  Ebstein^  is  very  similar  to  this  latter  case: 
Hb.,  62;  red  cells,  3,492,000;  but  the  leucocytes  are  unusu- 
ally high,  there  being  32,000  (differential  not  stated).  It  is 
impossible  at  present,  there  being  so  few  blood  counts  avail- 
able, to  come  to  any  definite  conclusion.  The  leucocytosis 
is  easily  accounted  for  by  the  inflaromatory  and  often  puru- 
lent processes  going  on  in  the  lungs.  Whether  there  is  a 
real  disproportion  between  the  number  of  red  cells  and  the 
percentage  of  haemoglobin,  thus  pointing  perhaps  to  some 
haemolytic  process,  or  whether  in  the  majority  of  cases  there 
is  only  the  usual  anaemia,  both  of  red  cells  and  of  haemo- 
globin, to  be  expected  in  any  case  of  increasing  malignancy, 
— especially  if  there  is  considerable  loss  of  blood, — is  a 
problem  that  awaits  further  study.  In  the  case  of  Cohen 
and  Kirkbride  the  disproportion  between  4,400,000  red  cells 
and  only  sixty  haemoglobin  is  very  striking.  The  blood 
counts   given    by  Faust  ^  show  some  resemblance   to   the 

1  Table  I,  Nos.  222  and  223.  *  Table  I,  No.  76. 

2  Table  I,  Nos.  2  and  4.  ^  Loc.  cit. 

3  Table  II,  No.  13. 


CLINICAL  85 

blood  counts  mentioned  here,  inasmuch  as  his  rabbits 
showed  a  continuous  decrease  in  the  haemoglobin  with  a 
comparative  increase  in  the  red  cells  and  a  tendency  to 
some  leucocytosis.  The  interesting  coincidence  is  certainly 
worthy  of  note. 

Miiller^  has  among  his  cases  no  case  of  lung  tumor. 
As  a  result  of  his  careful  blood  counts  nothing  character- 
istic is  shown.  The  haemoglobin  has  a  tendency  to  go 
down  steadily,  as  also  the  number  of  red  cells,  and  there 
is  a  tendency  to  leucocytosis  and  to  an  increase  of  the 
polynuclear  cells,  but  nothing  characteristic  of  the  blood 
in  lung  tumors  is  shown. 

IX.  Incidentally,  there  should  be  mentioned  two  cases  in 
which  diabetes  was  a  complication  of  the  disease,  as  in  the 
cases  of  Kratz^  and  Liibbe.^  There  is  no  evidence,  so  far 
as  can  be  seen,  that  the  diabetes  stands  in  any  relation  to 
the  lung  tumor. 

X.  The  clubbed  fingers  which  are  sometimes  reported 
have,  it  is  obvious,  no  specific  relation  to  malignant  growths. 
They  are  not  different  from  the  clubbed  fingers  that  we  see 
in  other  chronic  diseases,  especially  of  the  lungs,  and  more 
particularly  where  pus  is  present. 

1  Oswald  Miiller,  tjber  den  Blutbefund  bei  Krebskranken,  Diss.  Berlin, 
1909. 

2  Table  I,  No.  151.  » Table  I,  No.  187. 


CHAPTER  IX 

CLINICAL    {.Continued) 

WHEN  one  is  compelled  to  face  the  almost  infinite 
variety  of  pathological  lesions  and  compUcations 
that  are  associated  with  most  of  the  primary  malignant 
neoplasms  of  the  Imigs,  the  clinical  pictm^es  and  their 
symptomatology  appear  to  present  an  almost  hopeless  con- 
fusion. A  larger  experience  and  comparative  study  will 
show  that  there  is,  after  all,  a  certain  monotony  of  essen- 
tial sjTuptoms,  around  which  the  varying  complications  and 
lesions  are  grouped.  It  is  possible  in  this  way  to  arrange 
the  entire  clinical  material  at  our  disposal  into  certain  groups 
which,  with  their  subdivisions,  supply  a  fairly  well-classified 
arrangement  of  the  clinical  phenomena.  A  certain  number 
of  tumors,  as  has  been  shown  above,  are  apt  to  withdraw 
themselves  from  diagnosis  by  causing  no  symptoms  whatso- 
ever, and  others  in  which  a  diagnosis  is  not  likely  because 
symptoms  caused  by  metastatic  deposits^  completely  domi- 
nate the  chnical  picture  and  successfully  mask  the  pulmonary 
disease.  For  the  great  majority  of  tumors  which  do  produce 
symptoms,  the  remark  of  Stokes,  that  ''the  faciUty  of 
diagnosis  mainly  depends  on  the  anatomical  disposition  of 
the  disease,"  is  still  true. 

According  to  Passler,^  the  clinical  pictures  accom- 
panying pulmonary  mahgnant  neoplasms  can  be  aptly 
arranged  in  two  main  groups.     The  first  group  contains 

1  There  is  much  difference  of  opinion  among  authors  as  to  the  frequency  of 
metastases  in  maUgnant  tumors  of  the  lung,  some  claiming  that  secondary 
deposits  are  very  rare  in  carcinoma  and  correspondingly  numerous  in  sarcoma, 
others  expressing  directly  opposite  opinions.  By  consulting  Appendices  C 
and  D  the  reader  will  obtain  a  fair  idea  of  the  occurrence  of  metastases  in  the 
various  organs  both  in  carcinoma  and  in  sarcoma  and  he  will  find  very  little 
difference  between  carcinoma  and  sarcoma  in  this  respect. 

2  Loc.  cit. 

86 


CLINICAL  (Continued)  87 

the  cases  in  which  the  symptoms  referable  to  diseases  of 
the  lungs  and  bronchi  largely  predominate.  These  tumors, 
mostly  carcinoma,  nearly  always  take  their  origin  from  the 
bronchial  ramifications  from  the  second  order  downwards 
to  the  smaller  and  smallest  bronchioles,  and  as  a  rule  do 
not  directly  implicate  the  hilus.  The  second  group 
embraces  to  a  large  extent  the  tumors  of  the  root  of  the 
lung.  This  group  may  be  accompanied  by  intense  and 
agonizing  symptoms  on  the  part  of  the  respiratory  organs: 
lungs,  bronchi,  etc.;  but  these  are  usually  of  a  secondary 
nature,  though  they  may  dominate  the  clinical  picture. 
The  typical  symptoms  of  this  variety  of  lung  tumor  are 
largely  mechanical  and  composed  mainly  of  such  symp- 
toms as  result  from  pressure  on  or  compression  of  the  tho- 
racic organs,  especially  of  the  mediastinum,  and  from  the 
overcrowding  of  the  intrathoracic  spaces.  The  elementary 
symptoms  mentioned  above  are  common  to  both  groups. 

The  classification  of  Marfan,^  identical  in  principle  with 
that  of  Passler,  is  perhaps  a  little  more  convenient,  and  is 
adopted  here.     It  reads  as  follows: 

I.  The  acute  or  galloping  form  of  pleuro-pulmonic  cancer. 
II.  Chronic  pleuro-pulmonic  cancer. 

1.  Broncho-pulmonary  type,  being  the  classical  type  of  carcinoma 

of  the  lungs. 

2.  Type  suggesting  tiunor  of  the  mediastinum. 

3.  Pleuritic  type. 

(a)  Pleuritic  type  of   the  pleuro-pulmonary  tumor  without 
effusion. 

The  first  main  division,  the  acute  or  galloping  miliary  car- 
cinoma of  the  lungs,  runs  an  extremely  rapid  course,  accom- 
panied by  cough,  dyspnoea,  and  asphyxia;  death  usually 
in  a  month  or  thereabouts.  The  clinical  picture  in  many 
respects  resembles  that  of  acute  miliary  tuberculosis,  and  at 
autopsy  both  lungs  and  pleura  are  found  studded  with 
miliary  nodules  which,  however,  on  microscopic  examination, 
are  found  to  be  cancerous.  This  form  is  extremely  rare  and 
only  a  very  few  scattered  cases  have  been  reported.  The 
case  of  Elisberg2  may  possibly  come  under  this  heading.     In 

*  Quoted  from  Chauvain,  loc.  cit.  *  Table  I,  No.  80. 


88     PRIMARY  MALIGNANT  GROWTHS  OF  THE  LUNG 

this  case  the  primary  tumor  was  in  the  bronchus.  It  is 
generally  denied  that  this  form  of  carcinosis  ever  occurs 
as  a  primary  pulmonary  lesion.  This  statement,  however, 
cannot  be  supported  by  absolute  proof.  Granted  that  it 
does  occur  as  a  primary  lesion,  it  seems  that  at  present  there 
are  no  means  of  obtaining  a  correct  diagnosis  during  hfe. 

II.  The  chronic  pletjro-pulmonary  cancer.  This  is 
the  ordinary  chronic  form  of  cancer  of  the  lung,  in  which 
the  lungs,  bronchi,  and  pleura  are  mainly  affected  by  the 
tumor.  The  subdivisions  which  have  been  mentioned  are, 
it  is  necessary  to  insist,  merely  for  the  convenience  of  the 
clinician  and  do  not  represent  strictly  defined  and  firmly 
established  independent  syndromes.  With  the  progressive 
development  and  extension  of  the  blastomic  lesion,  accom- 
panied by  a  varying  degree  of  destruction  of  the  lung  and 
the  secondary  effects  of  the  tumor  on  its  environment,  the 
symptoms  must  necessarily  vary,  and  the  so-called  subor- 
dinate groups  may  merge  one  into  the  other.  It  may 
often  be  observed  that  several  or  all  of  the  various  types 
here  mentioned  are  exemplified  in  the  course  of  a  single 
case. 

1.  Pulmonary  cancer.  The  classical  type  of  cancer 
of  the  lung.  This  represents  the  ordinary  bronchial  carci- 
noma which,  as  shown  above,  is  by  far  the  most  frequent 
form  of  the  disease.  The  dominant  symptoms  are  referable 
mainly  to  the  lungs  and  bronchi.  The  earlier  stages  usually 
suggest  merely  a  chronic  bronchitis. 

It  is  commonly  said  that  in  the  very  earliest  stages  of  the 
development  of  the  tumor,  percussion  will  fail  to  show  any 
appreciable  difference  from  the  normal.  This  may,  in  the 
main,  be  true.  It  is,  however,  the  writer's  deep  conviction 
that,  even  in  very  early  stages,  percussion  may  be  found 
significantly  altered,  if  a  sufficiently  dehcate  technique  be 
adopted. 

It  cannot  fall  within  the  scope  of  this  study  to  enter  in 
detail  into  a  discussion  as  to  the  relative  values  of  the  vari- 
ous methods  of  percussion  or  into  the  manifold  theories 
that  have  been  put  forward  in  this  most  important  chap- 


CLINICAL   (Continued)  89 

ter  of  diagnostics.  But  it  is  the  writer's  opinion  that 
the  ordinary  loud,  resounding,  finger  to  finger  or  hammer 
to  finger  or  plessimetre  percussion  cannot  be  made  to 
give  proper  results  in  these  earher  stages.  The  writer  has 
employed  for  years  the  "  Schwellenwerthperkussion "  and 
orthopercussion  as  elaborated  by  Goldscheider,  Plesch, 
and  Curschmann,  in  combination  with  the  auscultatory 
percussion  according  to  Ewald  and  the  friction  method  of 
Bianchi.  The  results,  checked  by  the  orthodiascope,  have 
as  a  rule  been  most  satisfactory.  These  methods,  if  carried 
out  with  the  dehcacy  of  touch  and  hearing  which  they 
require,  may  be  expected  to  lead  to  the  detection  of  compara- 
tively slight  pathologic  lesions  where  other  methods  of  per- 
cussion will  fail.  It  is  understood  that  percussion  must  vary 
according  to  the  different  stages  of  development  and  the 
various  complications  that  may  occur  in  the  course  of 
malignant  disease  of  the  lungs. 

There  are  cases  on  record,  as  for  instance  that  of 
Rottman/  where  it  is  reported  that  physical  signs  on  the 
lungs  were  negative,  although  a  large  tumor  was  found. 
This  is  only  one  of  many  similar  examples  reported.  In 
early  stages  a  dull  percussion  note  is  found  at  one  apex  or 
the  other,  or,  which  is  much  more  difficult  to  find,  at  the 
hilus  posteriorly.  The  anterior  aspect  of  the  upper  chest 
is  more  frequently  the  seat  of  dulness  than  the  posterior, 
but  the  dulness  at  the  hilus,  of  course,  can  only  be  heard 
near  the  spine.  This  dulness  may  gradually  increase  from 
a  shght  change  in  the  percussion  note  to  absolute  flat- 
ness. The  flatness  and  boardlike  resistance  to  the  per- 
cussing finger  are  very  often  due,  not  to  the  tumor  itself, 
but  to  the  atelectasis  caused  by  the  tumor.  Woillez  2  desig- 
nated as  characteristic  of  lung  tumor  what  he  called  the 
'Hympanisme  thoracique,"  which  consists  of  a  tympanitic, 
immediately  preceding  the  full,  percussion  note.  This  has 
not  turned  out  to  be  a  pathognomonic  sign  and  is  wellnigh 
forgotten. 

1  Table  I,  No.  277. 

2  Dictionn.  de  Diagnost.  m6d.,  Paris,  1870,  2d  Ed. 


90     PRIMARY  MALIGNANT  GROWTHS  OF  THE  LUNG 

Characteristic  of  these  earher  stages  is,  further,  the 
fact  that  with  dull  or  flat  percussion,  auscultation  shows 
diminished  respiration.  Where  pleuritic  effusion  or  pleu- 
ritic adhesions  and  thickenings  can  be  excluded,  which  is 
comparatively  easy  for  the  upper  anterior  portions  of  the 
chest,  this  sign  of  increasing  dulness  with  diminishing  voice 
and  breathing  sounds  is  extremely  suggestive,  and  while 
not  absolutely  pathognomonic  of  tiunor,  should  make  the 
presence  of  tumor  highly  probable.  The  mechanism  of 
the  sign,  —  increasing  dulness  with  diminishing  voice  and 
breathing  without  pleuritic  effusion,  —  is  of  course  given  in 
the  more  or  less  complete  obstruction  of  a  bronchus,  by 
which  means  those  portions  of  the  lung  not  affected  by 
tumor  are  in  a  more  or  less  complete  state  of  atelectasis. 
Most  interesting  in  this  connection  is  the  case  reported  by 
Korner.i  In  this  case  there  was  flattening  of  the  right 
chest,  absolute  flatness  of  percussion,  and  entire  absence 
of  respiratory  and  vocal  sounds, — in  a  word  uncomphcated 
and  complete  obstruction  of  the  right  main  bronchus,  a  diag- 
nosis that  was  confirmed  by  autopsy.  The  area  of  dull  per- 
cussion note  in  these  cases  is  usually  sharply  defined,  as 
distinguished  from  tuberculosis  and  pneumonic  conditions, 
where  the  delimitation  is  more  diffused,  the  abnormal  per- 
cussion merging  gradually  into  the  normal.  The  configura- 
tion of  the  area  of  dulness  or  flatness  is,  however,  usually 
quite  irregular,  according  to  the  topographical  disposition 
of  the  tumor,  its  depth,  its  extension,  and  its  surrounding 
reactive  processes. 

As  the  tumor  grows  and  degenerations  of  various  kinds 
make  their  appearance,  as  breaking-down  and  irregular 
excavations  in  the  tumor  come  about,  —  and  it  has  been 
stated  above  that  this  happens  much  more  frequently  than 
most  authors  concede,  —  the  percussion  note  and  ausculta- 
tory signs  must  necessarily  change  in  character  and  become 
variable  to  a  considerable  extent.  Tympanitic  percussion 
note,  amphoric  breathing,  metallic  rales  will  show  the 
presence  of  a  cavity,  and  when  a  case  has  reached  this  stage 

1  Table  I,  No.  147. 


CLINICAL  (Continued)  91 

one  is  apt  to  pardon  the  clinician  who  does  not  hesitate  to 
diagnosticate  tuberculosis.  Besides  more  or  less  profuse 
haemorrhages,  it  is  not  unusual  to  find  at  this  stage  irregular 
fever  of  considerable  intensity  and  night  sweats.  The  fever 
may  resemble  the  hectic  type.  Notice  is  to  be  taken,  also, 
of  the  bronchiectatic  dilatations  which  occur  so  often  and  to 
so  great  an  extent,  as  a  consequence  of  obstructed  bronchi. 
Here  percussion  as  well  as  auscultation  offers  frequently 
interesting  changes.  If  the  bronchus  is  completely  closed 
for  a  long  time,  the  bronchiectatic  cavity  naturally  fills  with 
secretion,  —  pus,  mucus,  blood,  and  so  on,  —  possibly 
continually  dilating,  and  the  percussion  note  over  this  will 
be  dulness  to  flatness,  and  auscultation  will  hear  neither 
voice  nor  breathing.  Suddenly,  as  it  were,  the  bronchus  is 
reopened  by  ulceration  and  degeneration  of  the  obstructing 
tumor,  there  is  a  free  discharge  of  the  bronchiectatic  con- 
tents, and  in  the  place  where  formerly  there  was  abso- 
lute flatness,  we  have  now  the  tympanitic  note  and  the 
auscultatory  symptoms  pointing  to  a  cavity. 

It  is  obvious  that  these  signs  can  only  occiu"  in  very 
late  stages  of  the  disease.  The  process  may  be  varied 
in  different  ways  and  it  may  be  taken  as  characteristic 
of  these  later  ulcerative  stages  when  such  sudden  changes 
in  auscultation  and  percussion  appear.  As  a  good  illus- 
tration of  these  conditions  may  be  mentioned  the  case  of 
Amal.^  In  this  case  there  was  total  absence  of  breath- 
ing, but  normal  percussion  over  the  entire  right  lower 
lobe.  There  were  all  the  other  symptoms  of  a  malignant 
growth  in  the  lungs.  Very  suddenly,  and  only  a  few  days 
before  death,  the  respiratory  murmur  was  again  distinctly 
heard  over  the  right  lower  lobe,  —  in  other  words,  the  tumor, 
partly  compressing,  partly  proliferating  into  the  right  main 
bronchus  of  the  lower  lobe  and  completely  filling  it  and 
preventing  the  passage  of  air,  had  ulcerated  away  to  a 
great  extent  and  thus  again  permitted  communication  with 
the  air.  It  has  frequently  been  said  that  percussion  over  a 
neoplasm  of  the  lung  offers  a  greater  resistance  to  the  finger 

» Table  I,  No.  13. 


92     PRIMARY  MALIGNANT  GROWTHS  OF  THE  LUNG 

than  is  normal.  This  sign,  however,  depends  on  so  many 
varying  factors,  as  the  closeness  of  the  tumor  to  the  chest 
wall,  the  condition  of  the  lungj  etc.,  that  it  is  not  constant 
and  not  characteristic,  though  when  present  a  welcome 
corroboration. 

Another  sign  of  great  diagnostic  value  is  the  auscultatory 
symptom,  to  which  Behier  ^  gave  the  name  of  ''cornage." 
This  is  a  sound  very  similar  to  that  obtained  from  the 
trachea  when  partially  compressed.  It  is  pathognomonic  of 
bronchial  obstruction  and  might  be  considered,  especially 
when  heard  about  the  root  of  the  lungs,  and  better  still 
when  accompanied  by  some  dulness,  as  an  almost  certain 
sign  of  tumor.  It  must  be  remembered,  however  (and  for 
that  reason  the  word  ''almost"  is  inserted),  that  certain  other 
conditions  which  may  result  in  bronchial  obstruction  must 
be  excluded.  This  should  not  be  difficult,  for  probably  all 
the  processes  which  may  result  in  bronchial  obstruction, 
and  thus  in  an  audible  cornage,  are  acute.  Thus  it  is  not 
unusual  to  find  the  sign  in  acute,  severe  bronchitis  or  in  an 
influenza  pneumonia,  or  even  in  chi'onic  bronchitis  when  a 
bronchus  happens  to  be  obstructed  by  masses  of  viscous  and 
tenacious  mucus.  But  in  all  these  cases  the  obstruction  is 
temporary  and  disappears  as  a  rule  in  twenty-four  hours. 
But  in  tumor  the  cornage  is  practically  constant  and  will 
remain  so  until  the  bronchus  is  completely  obstructed,  or 
will  disappear  after  a  comparatively  long  time  when  the 
bronchus,  through  ulceration,  becomes  again  freely  perme- 
able to  air.     Cornage  may  be  a  very  early  symptom. 

2.  The  mediastinal  type  of  lung  tumor.  A  bronchial 
cancer,  —  and  it  is  indifferent  of  what  order  the  bronchus 
may  be,  whether  large  or  small,  —  has  two  main  preformed 
routes  of  extension  at  its  disposal.  The  easiest  and  most 
natural,  and  the  one  that  is  in  the  majority  of  cases  primarily 
resorted  to,  is  along  the  bronchial  ramifications  and  the 
peribronchial  tissues  into  the  interior  of  the  lung.  This 
holds  good  also  for  those  sarcomata  that  originate  in  the 
minute  peribronchial  glands  or  in  the  peribronchial  connec- 
1  Gaz.  de  Hop.,  AprU,  1867. 


CLINICAL  (Continued)  93 

tive  tissue.  In  the  later  stages  the  bronchial  wall  is  apt 
to  be  broken  down  and  penetrated  by  the  tumor,  and  thus 
the  bronchial  and  then  the  mediastinal  lymph  nodes  become 
involved  and  are  occasionally  enormously  enlarged.  The 
mediastinal  lymph  nodes,  possibly  both  anterior  and  pos- 
terior, now  take  part,  the  mediastinum  is  filled  with  tumor 
masses,  the  pericardium  may  be  covered  or  even  penetrated 
by  the  neoplasm,  pericarditis  develops,  secondary  growths 
in  the  heart  appear,  the  large  vessels,  both  aorta  and  cavse, 
the  pulmonary  arteries  and  veins  are  surrounded  and  either 
compressed  or  penetrated  by  the  tumor.  It  should  be 
mentioned  that  the  aorta,  while  often  much  compressed, 
so  far  as  the  writer's  knowledge  goes,  never  takes  part  in  the 
tumor  proliferation  and  is  never  penetrated  by  it.  As  a  con- 
sequence of  all  this  crowding  of  the  mediastinal  organs,  the 
superficial  veins  of  the  chest  are  dilated,  sometimes  to  a  huge 
extent,  and  cedcema,  varying  from  cedoema  of  a  single  arm, 
or  the  face,  to  a  general  oedoema  of  the  entire  body,  arises. 
One  or  the  other,  sometimes  both,  of  the  laryngeal  recurrent 
nerves  are  involved,  the  trachea,  large  bronchi,  oesophagus, 
are  compressed,  obstructed,  and  even  penetrated  by  the 
tumor.  The  participation  of  the  oesophagus  causes  the 
dysphagia  so  frequently  reported.  And  thus  all  the  symp- 
toms of  an  intrathoracic  growth,  or  more  especially  of 
primary  mediastinal  tumor,  are  evolved.  Sarcoma,  origi- 
nating at  the  hilus  of  either  lung,  differs  from  this  group  of 
symptoms  in  so  far  as  the  direction  of  the  growth  is  less 
towards  the  lung  and  tends  to  advance  more  rapidly  and 
at  an  earlier  stage  of  the  disease  toward  the  mediastinum. 
It  is  this  mediastinal  type  of  tumor  that  usually  causes 
the  dreadful  attacks  of  asphyxia  and  orthopnoea  mentioned 
above. 

3.  The  pleuritic  type.  In  cases  belonging  to  this  type, 
the  symptoms  referable  to  the  pleura  predominate.  So  far 
as  tumors  of  the  lungs  and  bronchi  are  concerned,  this 
form  corresponds  to  a  rather  late  stage  of  the  disease.  In 
primary  mahgnant  disease  of  the  pleura,  however,  which  is 
beyond  the  scope  of  this  monograph,  this  form  usually  marks 


94      PRIIMARY  MALIGNANT  GROWTHS  OF  THE  LUNG 

the  beginning  of  the  lesion.  The  symptoms  in  the  main 
are  those  of  acute,  sub-acute,  or  chronic  pleurisy.  There 
is  stabbing  pain  in  the  chest,  radiating  to  the  shoulders  or 
in  other  directions,  and  all  the  signs  of  a  persistent  pleuritic 
effusion,  which  too  often  tend  to  mask  more  or  less  com- 
pletely the  symptoms  of  pulmonary  disease.  We  have  the 
absolute  flatness  on  percussion,  the  total  absence  of  voice 
and  breathing  on  auscultation,  very  often  the  obliteration  of 
the  intercostal  spaces,  frequently  the  bulging  of  these  same 
spaces. 

In  nearly  every  case  of  lung  tumor,  the  pleura  partici- 
pates to  a  certain  extent  in  the  morbid  process,  sometimes 
with  sometimes  without  effusion;  according  to  Herrmann ^ 
in  fifty  per  cent  of  the  cases.  In  this  pleuritic  type,  how- 
ever, effusion  more  or  less  profuse  is  always  present  and  is 
hkely  to  recur  after  tapping  of  the  chest,  so  that  these 
tappings  must  be  repeated  again  and  again,  at  longer  or 
shorter  intervals.  In  ordinary  pleurisy  the  aspiration  of  the 
effusion  affords  prompt  reUef  of  the  harassing  symptoms. 
Even  in  the  pleurisy  associated  with  extensive  tuberculosis, 
this  rehef  can  be  recognized.  It  is  characteristic  of  the 
type  of  tumor  under  discussion  here,  —  though  it  applies 
also  to  primary  carcinoma  of  the  pleura,  —  that  relief  after 
removal  of  the  pleuritic  effusion  either  does  not  follow  at 
all,  or  lasts  but  a  very  short  time.  As  a  rule  there  is 
no  abatement  of  the  cough,  dyspnoea,  expectoration,  and 
general  distress,  but  there  may  be  intense  pain  caused  by 
the  wrenching  of  the  diseased  tissues.  Some  exceptions  to 
this  fairly  general  rule  are  on  record,  such  as  the  case  of 
Unverricht,2  where,  after  one  or  two  aspirations  of  sanguin- 
olent  fluid,  all  symptoms  seemed  to  disappear,  the  patient 
felt  entirely  well  and  gained  in  weight,  until  secondary 
tumors  made  their  appearance  in  the  skin  where  the  aspirat- 
ing needle  had  penetrated.     Hampeln^  also  reports  a  case 

1  Deut.  Archiv.  f .  klin.  Med.,  Vol.  63,  1899,  p.  583. 

^  Beitrage  zur  klin.  Geschichte  der  krebsigen  Pleuraerglisse,  Z'tschrift  f.  klin. 
Med.,  Vol.  IV,  1882,  pp.  79  ff. 
3  Table  I,  No.  101. 


CLINICAL   (Continued)  95 

in  which  the  pleuritic  effusion  was  absorbed  without  tapping 
and  without  recurrence.  These  cases,  however,  are  rare 
exceptions. 

The  fluid  recovered  by  the  first  few  tappings  may  be 
clear  yellow  serum,  but  sooner  or  later  it  is  certain  to 
become  bloody.  It  is  well  known  that  bloody  pleural 
effusion  occurs  in  other  diseases,  especially  in  tuberculosis, 
and  is  in  itself,  therefore,  not  pathognomonic  of  malignant 
tumor  of  the  lungs  or  pleura.  It  is  said,  however,  that  the 
change  from  initial  clear  serum  to  bloody  effusion  is  charac- 
teristic of  neoplasms  of  the  lung.  It  is  uncertain  whether 
this  is  correct  or  not.  It  is  reported,  on  the  other  hand, 
very  often  that  a  thick,  chocolate-hke  fluid  is  recovered  in 
the  later  tappings.  This,  according  to  the  writer's  opinion, 
is  certainly  pathognomonic  for  malignant  disease  in  the 
pleural  cavities.  Adipose  and  chylous  effusions  into  the 
pleura  are  reported,  but  are  found  very  rarely  in  malignant 
neoplasm  of  the  lung, — certainly  much  less  frequently  than 
in  the  disease  of  the  peritoneum.  The  same  holds  good 
for  empyema.  In  the  case  of  Walch^  it  was  evidently  a 
pneumococcic  affection  and  had  no  direct  relation  with  the 
carcinoma.  Nothing  characteristic  has  as  yet  been  found 
by  the  bacteriological  examination  of  the  pleuritic  effusions. 

The  results  of  the  cytological  examinations  have  been  a 
subject  of  much  discussion,  with  no  positive  conclusions. 
Ehrhch^  has  called  attention  to  the  diagnostic  importance 
of  the  presence  of  organically  connected  cell-groups  in  the 
effusion.  Frankel  has  called  attention  to  large  vacuolized 
cells,  sometimes  attaining  gigantic  dimensions.  These  are 
probably  tumor  elements  and  this  is  assured  if  they  are 
found  to  contain  glycogen,  but  they  probably  belong  to 
primary  diseases  of  the  pleura.  It  is  therefore  not  very 
difficult  to  diagnose  the  presence  of  malignant  tumor  in  the 
chest  from  the  study  of  the  cells  in  the  effusion,  if  such  can  be 
found.     It  is,  however,  almost  impossible,  under  the  condi- 

*  Cancer  du  poumon  gauche,  pleur^sie  purulente  pneumocoques,  Soc.  anat. 
de  Paris,  1893,  VII,  Ser.  5. 

» P.  Ehrlich,  Charit6-Annaleii,  1880,  Jahrg.  VII,  p.  226. 


96      PRIMARY  MALIGNANT  GROWTHS  OF  THE  LUNG 

tions  given,  to  distinguish  an  endothelial  from  an  epithelial 
cell,  and  therefore  a  primary  endothelioma  of  the  plem*a  from 
a  carcinoma  of  the  Imigs,  and  it  is  wise  not  to  depend  for 
diagnosis  on  the  cytology  of  the  pleural  exudate  alone. 
This  rule  should  hold,  even  though  exceptions  are  possible, 
as  in  the  case  of  HeUendall,^  who  found  in  the  bloody  effu- 
sion in  the  chest  white  particles  consisting  of  heaps  of  round 
cells,  sufi&ciently  characteristic  to  warrant  the  diagnosis  of 
sarcoma  of  the  lung,  —  a  diagnosis  which  was  confirmed 
by  autopsy.  Kronig,^  on  making  a  probatory  puncture, 
penetrated  the  tumor  with  the  needle  and  found  attached 
thereto  white  particles  which  microscopic  examination 
showed  to  be  lympho-sarcoma,  and  he  was  thus  enabled  to 
obtain  an  absolutely  certain  diagnosis  during  life.  He 
devised  a  method  based  on  this,  by  which  in  every  doubtful 
case  the  attempt  was  to  be  made  to  remove  particles  of 
tumor  by  aspiration.  There  are  serious  objections  to  this 
method.  It  is  not  only  very  uncertain  in  its  results,  as  the 
needle  does  not  always  return  with  tumor  particles,  but 
usually  only  with  a  little  blood,  but  there  is  actual  danger 
of  causing  a  haemorrhage. 

It  may  be  taken  as  a  trustworthy  sign  of  malignancy  if 
a  paralysis  of  the  recurrent  laryngeal  is  observed  on  the 
side  of  the  pleuritic  effusion.  It  has  been  stated  above 
that  as  a  rule  there  is  no  relief  after  removing  the  effu- 
sion in  cancerous  pleuritic  effusions.  It  may  also  be  said 
that,  after  removal  of  the  fluid,  the  various  phenomena 
of  percussion  and  auscultation,  which  until  then  had  been 
masked,  will  appear  in  unmistakable  distinctness,  and 
thus  greatly  assist  in  the  diagnosis.  The  dislocated  heart  * 
which,  on  removal  of  the  pleuritic  effusion,  will  make 
no  attempt  to  return  to  its  normal  place,  —  other  symp- 
toms being  favorable, — suggests  tumor.  The  retraction  of 
the  affected  side  of  the  thorax,  accompanied  by  increased 
dulness  and  impaired  or  entirely  abolished  respiratory 
motions,  when  caused  by  a  thickening  of  the  pleura,  some- 
times to  an  enormous  degree,  is  not  at  all  characteristic  of 
1  Table  II,  No.  35.  2  Table  II,  No.  42. 


CLINICAL   (Continued)  97 

malignant  growth  in  the  lungs  after  the  stage  of  effusion 
is  over,  but  is  well  known  to  occur  in  other  forms  of 
pleurisy,  especially  in  tuberculosis. 

(a)  The  pleuritic  type  without  effusion.  This  is  most 
typical  and  applies  almost  exclusively  to  those  large  mas- 
sive sarcomata  or  lympho-sarcomata  that  are  apt  to  fill  the 
greater  part  of  the  chest.  It  marks,  of  course,  a  late  stage 
of  the  disease.  There  are  all  the  signs  of  a  pleuritic  effu- 
sion, often  increased  circumference  of  the  side  of  the  chest 
involved,  displacement  of  the  heart,  etc.  There  may  also 
be  present,  but  not  necessarily  so,  the  ordinary  general 
symptoms  of  maUgnant  growth  of  the  lung,  —  the  cough, 
dyspnoea,  fever,  sweats,  haemoptysis,  cachexia,  etc.  The 
exploring  needle  fails  to  discover  any  fluid.  On  the  con- 
trary it  seems  to  penetrate  into  a  more  or  less  solid  mass 
extending  to  such  depths  as  to  preclude  any  possibility 
of  its  being  merely  an  abnormally  thickened  pleura.  Par- 
ticles of  tumor  may  be  brought  away  by  the  needle.  It 
is  characteristic  of  this  type  that,  while  there  is  complete 
absence  of  respiratory  murmur  or  vocal  fremitus,  there  is 
a  very  loud  propagation  of  the  heart  sounds,  so  that  if 
the  tumor  occupies,  for  instance,  the  right  chest,  the  heart 
sounds  can  be  heard  very  distinctly  over  the  whole  of  the 
right  chest,  both  in  front  and  in  back.^  This  sign  alone  is 
sufficient  to  assure  the  diagnosis  of  a  solid  intrathoracic 
mass.  Consequently  in  most  of  these  cases  there  is  dilata- 
tion of  the  superficial  veins  of  the  chest  and  possibly  of  those 
of  the  abdomen,  more  or  less  intense  dyspnoea,  paralysis 
of  one  or  both  recurrent  laryngeal  nerves,  direct  or  indirect 
affection  of  the  heart  itself,  the  large  vessels,  etc. 

A  few  words  should  be  said  concerning  some  morbid 
processes  which  are  found  in  the  train  of  pulmonary  tumors. 
Pneumonias,  both  acute  and  chronic,  are  among  the  most 
frequent  accompaniments  of  lung  tumors.  In  a  number  of 
cases  the  pneumonia  is  recorded  as  the  first  symptom.  The 
patients  state  that  they  were  taken  acutely  ill  with  chill, 
high  fever,  cough,  rusty  sputum,  from  which  they  recovered, 

1  Withauer,  Table  I,  No.  342.     Budd,  Table  III,  No.  13. 
8 


98       PRIMARY  MALIGNANT  GROWTHS  OF  THE  LUNG 

but  that  from  then  on  they  were  never  quite  well.  These 
acute  pneumonias  may  be  pneumococcic  pneumonias  or  pro- 
duced by  other  well-known  bacteria.  The  chronic  form,  if 
not  of  the  cheesy  tubercular  character,  is  principally  of  the 
indurative  type.  These  pneumonias  may  lead  to  symptoms 
which  mask  the  signs  of  the  tumor,  or  at  least  are  most 
perplexing.  Sometimes,  though  rarely,  they  are  followed 
by  a  genuine  empyema.  Atelectasis  ^  has  been  mentioned 
above  and  is  the  natural  consequence  of  the  blocking  by 
tumor  of  larger  or  smaller  bronchi,  resulting  in  the  collapse 
of  the  entire  territory  which  the  bronchus  supphes  with  air, 
as  well  as  its  splenification,  if  no  change  occurs  in  the 
bronchus.  There  will  be  moderate  dulness  on  percussion, 
though  sometimes,  —  particularly  if  the  area  is  small,  — 
the  percussion  note  will  remain  fairly  normal.  But  vocal 
fremitus  and  breathing  sounds  are  completely  abolished. 
It  is  on  account  of  these  secondary  processes  that  the 
extent  of  the  dull  area  does  not  coincide  with  the  actual 
size  of  the  tumor.  The  tumor,  as  the  X-rays  have  shown,^ 
may  be  larger  than  the  dull  percussion  would  lead  one  to 
expect.  On  the  other  hand  these  secondary  processes  give 
a  dull  percussion  note  of  their  own,  which,  merging  into 
that  caused  by  the  tumor,  is  apt  to  give  an  exaggerated 
idea  of  the  tumor's  size. 

Another  complication  which  requires  mention,  though 
abeady  hinted  at  above,  is  gangrene.  It  is  easily  conceiv- 
able, in  fact  it  is  almost  self-evident,  that  a  proliferating 
tumor  in  the  lung,  rapidly  destroying  lung  tissue  and  pene- 
trating into  blood  vessels,  can  at  any  time  envelop  and,  by 
compression,  obstruct  an  artery  of  some  size,  or,  by  breaking 
through  the  arterial  wall,  close  an  artery  completely,  and 
by  either  of  these  means  cause  total  ischsemia,  followed  by 
gangrene.  According  to  the  size  of  the  artery  involved, 
the  gangrenous  territory  will  be  larger  or  smaller,  occasion- 
ally occupying  the  greater  part  of  a  lobe.  When  a  case  is 
first  seen  in  this  condition,  the  diagnosis  is  intensely  diffi- 
cult, —  wellnigh  impossible,  —  as  even  those  signs  in  the 

^  Korner,  loc.  cit.  '  Leo,  loc.  cit. 


CLINICAL  (Continued)  99 

sputum  which  we  have  found  to  be  pathognomonic  are  apt 
to  be  lacking.  Under  these  conditions,  too,  the  X-rays 
will  not  give  any  useful  information,  and  it  is  only  by  most 
careful  study  of  the  history  and  the  progress  of  the  disease 
that  a  probable  diagnosis  can  be  arrived  at.  On  the  other 
hand,  if  the  gangrene  appears,  after  previous  examination 
and  observation  of  the  patient  have  settled  the  diagnosis 
of  tumor,  or  at  least  have  caused  tumor  to  be  suspected, 
the  gangrene  will  rank  only  as  a  complication.  It  may  be 
casually  added  that  there  may  be  interesting  involvements 
of  the  sympathetic  which  will  in  no  wise  interfere  with  the 
cardinal  symptoms  and  the  diagnosis,  but  which  are  of 
interest  as  again  demonstrating  the  manifold  complications 
that  are  constantly  arising.^ 

It  was  not  very  long  ago  that  A.  Frankel  ^  wrote  that  the 
X-rays  were  of  little  service  in  the  diagnosis  of  lung  tumors. 
Since  then  the  X-rays  have  become  a  most  remarkable  and 
efficient  aid  to  diagnosis  in  general,  and  there  exists  the 
well-founded  hope  of  their  increasing  efficiency  as  further 
improvements  in  the  apparatus  and  advances  in  technique 
are  made.  They  have  also  proved,  as  is  well  known,  a 
powerful  therapeutic  agent  in  many  diseases,  but  not  as  yet 
for  treatment  of  lung  tumors.  The  hope  may  reasonably 
be  entertained  that  with  the  systematic  and  proper  appli- 
cation of  the  X-rays  to  the  exploration  of  the  chest,  the 
diagnosis  of  lung  tumor  may  be  assured  when  no  other  means 
will  give  equally  certain  results.  Leo^  diagnosticated  an 
osteosarcoma  of  the  lungs,  secondary  to  a  sarcoma  of  the 
right  knee,  during  life,  with  certainty  and  much  topograph- 
ical detail  by  means  of  the  X-rays,  which  also  showed  a  much 
greater  extent  of  the  tumor  than  could  be  ascertained  by 
percussion  and  auscultation.  It  may  also  be  possible,  per- 
haps, to  obtain  this  diagnosis  at  a  time  when  the  tumor  is  as 
yet  very  small  and  causing  but  little  subjective  distiu-bance. 

If  this  happy  result  is  ever  to  be  reahzed,  it  will  be  neces- 

^  Kronig,  loc.  cit.  ^  Loc.  cit. 

'  Nachweis  eines  Osteosarkoms  der  Lunge  durch  Rontgenstrahlen,  Berl. 
Klin.  Woch.,  Vol.  XXXV,  1898,  No.  16,  p.  349. 


100    PRIMARY  MALIGNANT  GROWTHS  OF  THE  LUNG 

sary  to  examine  the  chest  with  the  Rontgen  rays  even  where 
there  are  no  symptoms  pointing  to  any  disease  in  the  chest. 
It  has  been  the  writer's  practice  for  a  great  many  years,  as 
an  essential  part  of  the  routine  examination  in  every  case  that 
presents  itself  at  his  office,  no  matter  what  the  patient's 
complaint,  to  subject  the  chest  to  a  thorough  exploration 
with  the  Rontgen  rays.  We  prefer  the  examination  with  the 
orthodiascope  (de  la  Campe)  and  a  very  large  (12'''xl6") 
fluorescent  screen.  Thus  one  is  enabled  at  a  single  glance 
to  observe  heart,  lungs,  in  fact,  taking  advantage  of  various 
positions,  nearly  all  the  thoracic  contents  during  action.  It 
is  particularly  useful,  also,  for  watching  the  respiratory 
mobiUty  of  the  lungs  and  diaphragm.  It  has  repeatedly 
been  noted  that  in  lung  tumor  the  mobihty  of  the  lung  is 
markedly  diminished  or  entirely  abolished.  In  cases  of  medi- 
astinal tumor  the  respiratory  mobility  of  the  lung  remains 
unchanged  or  is  increased,  and  Jacobson  ^  has  found  this 
valuable  in  distinguishing  between  the  two  types  of  tumor. 
With  good  light,  good  apparatus,  and  some  experience,  com- 
paratively minute  lesions  in  the  lungs  can  be  discovered. 
Any  abnormality  that  is  thus  brought  to  notice  can  be  per- 
manently fixed  for  further  reference  by  the  photographic 
plate,  approximately  accmrate  measurements  can  be  ob- 
tained, and  thus  the  gradual  enlargement  of  the  tumor 
verified  and  its  blastomic  nature  determined.  The  shadow 
of  a  carcinoma  or  sarcoma  just  starting  from  the  hilus  and 
gradually  extending  toward  one  of  the  pulmonary  lobes  is 
a  very  striking  picture  when  seen  with  the  Rontgen  rays, 
and  often  suggests  the  tumor  diagnosis  when  the  observer, 
though  other  characteristic  symptoms  were  present,  would 
have  been  led  astray.  The  interpretation  is  more  difficult 
when  the  shadow  extends  over  the  upper  lobe  of  either  side, 
as  this  is  the  favorite  localization  of  tuberculous  processes. 
Sometimes  the  sharp  hnear  delimitation  at  the  base  of 
the  shadow  makes  for  tumor  rather  than  tuberculosis.  It 
speaks  for  tumor,  also,  if  the  affection  is  confined  to  one 

*  Primare  Lungen  vmd  Mediastinal  Tumoren,  Festschr.  f.  Lazarus,  Berlin, 
1889. 


CLINICAL  (Continued)  101 

upper  lobe,  for  as  these  pictures  are  seen  only  after  the  dis- 
ease has  progressed  to  a  certain  extent,  the  upper  lobes  of 
both  lungs,  if  the  process  were  tuberculous,  would  probably 
have  been  affected.  The  shadow  remaining  unilateral 
speaks  for  tumor.  The  absence  of  tubercle  bacilli  in  the 
bloody  sputum,  with  the  increasing  shadow  on  one  lobe  only, 
also  suggests  tumor.  But  where  tuberculosis  is  associated 
with  advancing  carcinoma  or  sarcoma  of  the  lung,  the 
Rontgen  rays  are  of  Uttle  value,  and  if  a  differential  diag- 
nosis is  possible,  it  must  be  attempted  by  other  means. 
It  is  beyond  the  scope  of  this  study  to  enter  into  further 
details  concerning  the  X-rays.  The  reader  is  referred  to 
the  well-known  books  of  Holzknecht,^  Grodel,^  Grunmach,^ 
and  Amsperger.*  The  details,  however,  as  to  the  value  of 
the  X-rays  in  malignant  lung  tumors  may  be  studied  by  the 
reader  in  the  cases  recorded  by  Otten  ^  and  Muser,^  from 
the  Eppendorf  Krankenhaus,  Hamburg,  under  the  direction 
of  Lenhartz. 

Another  recent  aid  to  diagnosis  is  the  bronchoscope,  that 
has  been  so  successfully  employed  in  various  affections  of 
the  trachea  and  the  larger  bronchi.  It  has  also  done  service 
in  establishing  beyond  doubt  the  presence  of  a  bronchial 
neoplasm.  7  Karrenstein^  reports  the  case  of  a  male  forty- 
eight  years  of  age,  in  which  the  tumor,  taking  origin  from 
the  large  bronchus  immediately  below  the  first  division 
of  the  right  main  bronchus,  was  made  distinctly  visi- 
ble by  the  bronchoscope,  the  tumor  having  been  suspected. 
H.  von  Schrotter  ^  reports  a  case  of  a  male  f  orty-foiu- 
years  of  age  where  the  bronchoscope  showed  very  plainly 

^  Mitteil.  aus  Laboratorium  fiir  radiologische  Diagnostik  und  Therapie, 
Jena,  1907. 

2  Rontgendiagnostik  in  der  inn.  Med.,  Miinch.,  1909. 

2  tiber  die  diagnostische  und  ther.  Bedeutung  der  X-Strahlen  f.  d.  inn. 
Med.  u.  Chir.,  Deut.  Med.  Woch.,  1899,  No.  37. 

*  Die  Rontgenuntersuchung  der  Brustorgane,  Leipzig,  1909. 

6  Table  I,  No.  228. 

6  Table  I,  No.  205. 

^  Killian,  Zur  diagnostischen  Verwertung  der  oberen  Bronchoskopie  bei 
Lungencarcinom,  Berl.  Klin.  Wochenschr.,  1900,  p.  437. 

8  Table  I,  No.  141. 

«  Table  I,  No.  325. 


102    PRIMARY  MALIGNANT  GROWTHS  OF  THE  LUNG 

a  prominent  tumor  in  the  right  bronchus  from  which  a 
piece  was  exsected  for  microscopic  examination,  which 
showed  cancerous  epitheUa  with  glycogen  reaction,  and 
thereby  settled  the  diagnosis. 

It  is  always  unwise  to  endeavor  to  prophesy  as  to  future 
possibilities,  at  least  within  the  domain  of  biology  and 
pathology.  It  cannot  be  denied  that  the  field  of  bron- 
choscopy may  be  greatly  extended  by  improvements  in  appa- 
ratus and  in  technique.  It  is,  however,  the  writer's  opinion 
that  its  usefulness  in  the  diagnostics  of  lung  tumor,  at  this 
writing  at  least,  is  limited.  It  appears  at  present  that  from 
the  nature  of  things,  bronchoscopy  can  make  visible  only 
such  tumors  as  have  involved  the  upper  bronchi.  Of  what 
occurs  in  the  bronchi  of  lower  orders  and  in  the  depths  of 
the  lung,  the  bronchoscope  leaves  us  in  utter  ignorance. 
Moreover,  there  are  undoubtedly  many  cases  that  come 
under  observation,  late  in  the  course  of  the  disease,  where 
the  dyspnoea,  brain  involvements,  and  other  concomitant 
symptoms  are  of  such  gravity,  and  menace  life  to  such  a 
degree,  that  even  the  boldest  would  hesitate  to  introduce  a 
bronchoscope,  though  there  remained  but  little  doubt  that 
the  instrument  could  make  visible  the  involvement  of  the 
upper  bronchi.  In  such  cases  the  diagnosis  should  be  made 
by  other  means,  —  especially  as  even  the  exact  recognition 
of  the  tumor  by  the  bronchoscope  would  be  of  little  avail 
to  the  patient. 

In  concluding  the  clinical  part  of  the  subject,  it  is  still 
necessary  to  mention  a  few  points  which  may  be  helpful 
in  differentiating  lung  tumors  from  other  diseases  closely 
resembling  them  in  symptomatology,  and  for  which  they 
might  easily  be  mistaken.  First  and  foremost,  of  course, 
is  the  question — tuberculosis  or  tumor?  This  question  can 
be  easily  answered  at  autopsy,  but  it  is  not  quite  so  simple 
in  the  living  person.  Some  points  in  the  differential  diag- 
nosis have  already  been  brought  out.  The  small  tumors, 
particularly  cancroids,  described  as  growing  from  the 
walls  of  a  tuberculous  cavity,  will  probably  never  be  diag- 
nosticated, unless  pathognomonic  cells  in  the  sputum  direct 


CLINICAL  (Continued)  103 

attention  to  the  possible  existence  of  tumor  in  the  respiratory 
system.  At  any  rate  it  is  always  advisable  to  remember 
the  exhortation  of  Gerhardt,  —  always  to  suspect  tumor  in 
persons  of  advanced  age  where  tuberculosis  is  not  likely 
and  cannot  be  found  by  ordinary  examination,  and  where 
there  is  cough  with  bloody  expectoration.  It  is  plain 
that  the  differential  diagnosis  as  between  tuberculosis  and 
tumor  cannot  be  made  at  once,  but  requires  prolonged  and 
most  careful  examination  and  observation.  Even  then  it 
will  often  be  impossible  to  decide  absolutely.  That  it  can 
be  done,  however,  is  shown,  among  others,  by  the  follow- 
ing case  of  Fessen.^  This  concerned  a  man  forty-five  years 
old,  who  had  pulmonary  phthisis  and  a  cavity  in  the  right 
apex.  Tubercle  bacilli  were  found  in  the  sputum.  The 
tuberculosis  gradually  improved  and  showed  signs  of 
cicatrization.  Opposed  to  this,  however,  was  the  cough  with 
scant  expectoration,  the  general  cachexia  and  sharply 
defined  complete  flatness.  The  puncture  was  negative; 
the  Rontgen  rays  showed  a  dense  shadow,  very  sharply 
defined  at  its  lower  border.  This  alone  sufficed  to  justify 
a  diagnosis  of  tumor  of  the  lung.  This  diagnosis  was 
corroborated  by  the  bulging  of  the  intercostal  spaces,  the 
dilatation  of  the  veins,  the  small  radial  pulse  on  the  affected 
side  of  the  chest,  the  oedcema,  and  all  the  symptoms  of  a 
bronchial  obstruction  completing  the  clinical  picture.  The 
autopsy  showed  a  cicatrized  tuberculosis  of  the  left  lung, 
and  in  the  right  apex  a  cavity,  and  the  lower  portion  of  the 
right  upper  lobe  cancerous. ^  The  sudden  changes  in  percus- 
sion and  auscultation,  of  which  mention  has  been  made,  are 
not  likely  to  occur  in  tuberculosis,  but  speak  for  tumor.  The 
absence  of  bacilli  in  the  sputum,  it  is  hardly  necessary  to 
mention,  may  persist  for  a  long  time  in  tuberculosis,  but  in 
advanced  cases,  especially  where  extensive  ulceration  has 
taken  place,  tubercle  bacilli  are  sure  to  make  their  appear- 
ance. The  modern  tests  for  tuberculosis,  —  the  injection 
test,  the  Wolff-Eisner  and  von  Pirquet  tests,  —  will  only  be 
helpful  if  persistently  negative,  as  only  in  that  case  do  they 

1  Centralbl.  f.  innere  Med.,  1906,  No.  1.  «  Wolff,  loc.  cit.,  p.  817. 


104    PRIMARY  MALIGNANT  GROWTHS  OF  THE  LUNG 

help  to  exclude  the  presence  of  active  tuberculosis.  Further 
experience  and  improvement  in  methods  may  possibly 
result  in  greater  facility  and  precision  of  this  diagnosis. 
Enough  has  been  said  to  show  that  no  hard-and-fast  rules 
can  be  given  to  diagnosticate  lung  tumor  in  a  tuberculous 
individual.  The  hints  as  to  differential  diagnosis  that  have 
been  given  may  serve  in  a  general  way  as  guides,  but  the 
physician  must  mainly  depend  upon  his  own  insight  and 
judgment  in  each  individual  case. 

If  a  lung  tumor  happens  to  be  first  seen  when  it  is  far 
advanced,  the  suspicion  of  the  presence  of  an  aneurysm 
may  arise.  This  is  hardly  to  be  expected  in  the  ordinary 
case  of  carcinoma  of  the  lungs,  where  the  history,  the  train 
of  symptoms  as  outlined,  the  cells  in  the  sputum,  etc.,  will 
speak  against  aneurysm,  although  as  a  matter  of  fact  an 
aortic  aneurysm  is  rarely  to  be  absolutely  excluded.  The 
differentiation  as  between  sarcoma  and  aneurysm  is  some- 
what more  difficult,  as  sarcoma  naturally  tends  to  grow  more 
towards  the  mediastinum  and  away  from  the  lungs  than 
does  carcinoma.  In  some  cases  the  Rontgen  rays  may  help, 
although  as  a  rule  they  are  useless.  A  tumor  lying  upon 
or  adherent  to  the  aorta  will  pulsate.  The  pulsation  is 
generally  of  a  lesser  extent  and  more  definitely  circumscribed 
in  aneurysm,  while  in  the  case  of  tumor  it  is  of  a  more 
diffused  character,  involving  sometimes  the  entire  chest. 
The  difference  in  the  radial  pulse,  as  mentioned  above, 
a  common  sign  in  pulmonary  tumor,  will  not  aid  in  recog- 
nizing an  aneurysm  unless  the  smaller  pulse  is  found  on  the 
side  opposite  to  that  to  which  all  indications  point  as  the 
seat  of  the  tumor.  A.  Frankel  and  others  called  attention 
to  the  fact  that  lung  tumors  usually  cause  a  paralysis  of  both 
recurrent  laryngeal  nerves,  while  in  the  ordinary  forms  of 
aneurysm  of  the  arch  of  the  aorta  it  is  only  the  left  laryn- 
geal recurrent  that  is  affected.  Only  in  exceedingly  rare 
cases,  in  cases  of  enormous  size  of  the  aneurysm  or  of  mul- 
tiple aneurysms,  has  paralysis  of  both  laryngeal  nerves  been 
observed.^  As  the  case  proceeds,  secondary  visible  or  pal- 
» Baumler,  Deut.  Archiv.  f .  klin.  Med.,  Vol.  II,  p.  563. 


CLINICAL  (Continued)  105 

pable  tumors,  the  usual  characteristics,  etc.,  will  assure  the 
diagnosis  of  tumor,  to  the  probable  exclusion  of  aneurysm. 
The  tendency  for  the  spreading  and  enlargement  of  aneurysm 
is  natm-ally  more  toward  the  left  than  toward  the  right  side. 
This  fact  may  occasionally  be  of  some  use  in  diagnosis. 

Stokes  and  Graves  mentioned  a  certain  asymmetry  of 
the  thorax  in  cases  of  malignant  neoplasm  of  the  lung. 
A.  Frankel  and  others  have  in  recent  times  called  attention 
to  this  as  an  almost  pathognomonic  symptom.  The  asym- 
metry consists  in  the  retraction  of  that  side  of  the  chest 
where  the  tumor  is  supposed  to  be  localized,  especially  in  its 
posterior  and  lateral  aspects,  after  tapping  of  the  pleuritic 
effusion.  This  ^'r^tr^cissement  thoracique"  is  supposed  to 
be  caused  by  the  rapid  involvement  of  the  pleura,  with  its 
consequent  thickening,  by  which  the  proper  expansion  of 
the  lung  is  prevented. 

As  a  curiosity  which  does  not  occur  very  frequently,  but 
which,  when  it  does  happen,  can  hardly  be  distinguished 
from  primary  malignant  tumor  of  the  lung,  see  the  case  of 
Boris. ^  In  this  case  there  were  all  the  symptoms  from  which 
a  diagnosis  of  primary  malignant  neoplasm  of  the  lung  could 
have  been  made,  though  the  clinical  diagnosis  was  tuber- 
culosis. At  autopsy  no  positive  anatomical  diagnosis  was 
attainable  and  it  was  only  through  microscopic  examination 
that  the  tumor  was  found  to  be  chorionepithelioma,  the 
primary  focus  being  an  insignificant  and  easily  overlooked 
spot  in  the  broad  ligament.  The  case  of  Couvelere  ^  may 
also  be  mentioned  as  one  of  those  congenital  cystadenoma- 
tous  structures  which  might  occasionally  be  confounded  with 
primary  malignant  tumor.  A  glance  at  some  of  the  other 
cases  recorded  in  Table  IV  will  show  a  number  of  instances 
of  congenital  adenomatous,  cystic,  and  some  secondary, 
tumors  of  the  lung  which  might  be  confounded  with  pri- 
mary malignant  neoplasms,  and  in  many  cases  the  differ- 
ential diagnosis  will  be  almost  impossible.  There  are  some 
of  particular  interest,  as  the  case  of  Dionisi,'  the  case  of 

» Table  IV,  No.  1.  » Table  IV,  No.  6. 

» Table  IV,  No.  7. 


106    PRIMARY  MALIGNANT  GROWTHS  OF  THE  LUNG 

Lesieur  et  Rome.^  In  the  latter  there  was  a  large  massive 
cyhndrical  celled  typical  carcinoma  in  the  lung,  where  only 
a  careful  autopsy  showed  the  primary  focus  to  be  a  very 
insignificant  nodule  in  the  rectum.  The  tumor  in  the  lung 
had  precisely  the  character  of  the  rectal  cancer  and  is  further 
remarkable  for  the  fact  that  it  is  the  only  secondary  tumor 
of  the  lung  on  record  which  consists  of  one  large  massive 
growth.  The  case  of  Laseque  ^  is  also  to  be  noted  as  a  case 
of  lympho-sarcoma,  where  the  primary  focus  could  not  posi- 
tively be  determined,  but  may  have  been  in  the  lung,  and 
the  case  is  remarkable  for  the  very  unusual  generalization 
of  the  lympho-sarcoma  simulating  a  primary  tumor.  The 
cases  of  dermoid  tumor  of  the  lung,  —  that  of  Sommers  ^ 
and  Sormani,^  —  though  they  may  in  many  respects,  for  a 
time  at  least,  be  mistaken  for  primary  malignant  neoplasm 
of  the  lung,  will  soon  appear  in  their  true  nature  by  the 
expectoration  of  hair  and  other  dermoid  components. 
Of  great  interest,  also,  is  the  case  of  Linser,^  which  might 
easily  have  been  mistaken  for  a  malignant  tumor  of  the 
lung,  but  which  on  autopsy  turned  out  to  be  a  congenital 
cyst-adenoma  of  the  lung  with  a  profuse  production  of 
mucus.  Boecker,^  when  presenting  his  interesting  case  of 
the  production  of  mucus  in  a  case  of  carcinoma  of  the  lung, 
speaks  also  of  the  cases  of  Lohlein^  and  Helly.^  He  be- 
lieves that  Lohlein's  case  is  a  genuine  case  of  carcinoma  with 
profuse  production  of  mucus.  The  character  of  Helly's 
case  is  not  yet  satisfactorily  determined.  There  is  also  to 
be  mentioned  the  case  of  Jores.^  In  this  case  a  dermoid 
cyst  of  the  left  lung  was  connected  with  a  maUgnant 
cysto-sarcoma.    It  is  not  necessary  to  go  into  the  details 

1  Table  IV,  No.  13. 

2  Table  IV,  No.  12. 
»  Table  IV,  No.  17. 
*  Table  IV,  No.  18. 

^  t)ber  einen  Fall  von  congenitalem  Lungen-Adenom,  Virch.  Archiv.,  No. 
157,  p.  281. 
^  Loc.  cit. 

7  Table  IV,  No.  14. 

8  Table  I,  No.  122. 

®  tlber  die  Verbindung  einer  Dermoidcyste  mit  malignem  Cystosarcom 
der  linken  Lunge,  Virch.  Arch.,  No.  133,  p.  66. 


CLINICAL   (Continued)  107 

of  the  case.     There  seems  no  doubt  that  the  sarcoma  was 
developed  secondary  to  the  congenital  dermoid  cysts. 

It  is  customary,  in  the  study  of  any  clinical  subject,  to 
conclude  with  a  careful  discussion  of  the  treatment.  The 
treatment  of  primary  malignant  growths  of  the  lung  has  not 
required  much  discussion  in  the  textbooks  up  to  date,  and 
if  mentioned  at  all  is  finished  off  with  one  or  two  lines. 
The  diagnosis  of  a  cancer  of  the  lung  was  the  death-warrant 
of  the  patient.  In  former  times,  before  medicine  determined 
to  become  one  of  the  natural  sciences,  the  patients  were 
treated,  not  for  cure,  but  for  relief,  by  all  sorts  of  barbarous 
means.  It  is  about  one  hundred  years  ago  that  Heyf elder, ^ 
disgusted  with  the  treatment  that  these  unfortunates  were 
receiving  under  all  sorts  of  diagnoses,  —  the  blood-letting, 
the  purging,  the  salivation,  etc.,  —  urged  upon  physicians 
the  necessity  of  recognizing  these  cases  as  cancer  and  as 
hopeless,  and  begs  them  not  to  add  the  torture  of  medical 
treatment  to  the  sufferings  consequent  upon  the  disease 
itself.  "Optima  hie  est  medicina,  medicinam  non  facere." 
Present-day  medicine  treats  these  cases  purely  symptomat- 
ically  with  the  sole  object  of  relief,  and  the  interest  attaching 
to  an  accurate  diagnosis  is  mainly  theoretical  and  scientific. 
It  is  not  to  be  wondered  at  that  the  physician  takes  little 
interest  in  types  of  diseases  that  offer  not  the  slightest  hope 
of  therapeutic  success.  It  cannot  really,  he  thinks,  if  he 
thinks  at  all,  make  any  difference  to  the  patient  if  he  is  to 
die  of  a  pulmonary  phthisis  or  of  a  far  advanced  pulmonary 
cancer.  It  is  not  very  many  years  ago  that  Benda^  was 
justified  in  asserting  that  cancer  of  the  lung  occupied  a 
unique  position,  inasmuch  as  it  was  the  only  cancer  that 
was  absolutely  beyond  the  reach  of  the  surgeon;  but  he 
went  a  step  further  and  added  that  no  matter  what  progress 
surgery  might  make,  it  could  never  hope  to  deal  satisfactorily 
with  lung  cancer,  as  it  would  always  remain  impossible  to 
make  the  diagnosis  early  enough  for  any  reasonable  expecta- 

*  Loc.  cit. 

^  Zur  Kenntniss  des  Pflasterzellenkrebses  der  Bronchien,  Deut.  Med. 
Wochenschr.,   1904,   p.   1454. 


108    PRIMARY  MALIGNANT  GROWTHS  OF  THE  LUNG 

tion  of  a  cure  by  surgical  interference.  This  is  a  practical 
illustration  of  how  unwise  it  is  to  attempt  to  set  hmits  to 
the  progress  of  science.  Since  Benda  made  this  daring  state- 
ment, matters  have  completely  changed.  The  technique 
of  thoracic  surgery  and  especially  of  lung  surgery,  —  thanks 
to  the  efforts  of  Brauer,^  Friedrich,^  and  Garre  and  Quincke,  ^ 
and  in  a  more  practical  maimer  the  efforts  of  Sauerbruch, 
Willy  Meyer,  Meltzer,  and  Lenhartz,  —  though  evidently 
still  in  its  beginning,  has  already  developed  to  a  marvellous 
degree.  Lenhartz  ^  succeeded  in  operating  several  cases 
of  cancer  of  the  lung,  and  in  one  case,  to  all  appearances 
desperate  and  hopeless,  by  removing  the  affected  lobe  in 
its  entirety,  prolonged  the  patient's  life  for  a  year  and  a 
half,  and  with  comparative  comfort.  There  is  every  reason 
to  hope  that  the  technique  of  this  new  branch  of  surgery 
will  be  still  fiuther  developed  and  that  in  the  near  future 
thoracotomy  and  operations  on  the  lungs  will  be  attended 
with  no  more  risk  than  are  peritoneal  operations  to-day. 
If  this  is  so,  a  new  and  great  responsibility  is  placed  upon  the 
shoulders  of  internal  medicine.  It  will  be  necessary,  not 
only  to  educate  the  opinion  of  the  laity  so  as  to  induce  them 
to  submit  to  these  operations  with  the  same  readiness  with 
which  they  now  submit  to  peritoneal  operations,  but  it  will 
also  be  the  sacred  duty  of  the  physician  to  recognize  these 
cases  and  to  recognize  them  as  early  as  possible.  The  physi- 
cian must  be  imbued  with  the  conviction  that  malignant 
pulmonary  disease  occurs  much  more  frequently  than  is 
commonly  beUeved  and  that  he  may  meet  it  any  day  in  his 
practice  among  the  young,  as  well  as  among  the  old.  As  at 
present  the  conscientious  physician  examines  every  chest 
for  possible  tuberculosis,  so  in  the  future  every  chest  will 
have  to  be  examined  for  possible  tumor.  The  writer  would 
go  still  further.  Where  all  the  means  of  diagnosis  outlined 
in  this  httle  study  fail,  where  there  is  suspicion  of  tumor, 

^  Referat  uber  Lungenchirurgie,  Verhandl.  der  Gesellschaft  Deut.  Natur- 
forscher  und  Artze,  September,  1908. 

*  Die  Chirurgie  der  Lungen,  Archiv.  f.  klin.  Chir.,  1907,  Vol.  82,  p.  1147. 

*  Grundriss  der  Lungenchirurgie,  Jena,  1903. 

*  Conf .  the  various  pubhcations  of  the  Hamburger  Staatskrankenhaus. 


CLINICAL   (Continued)  109 

but  no  assurance  is  possible,  there  should  be,  —  it  is  emphat- 
ically here  stated,  —  as  httle  hesitation  in  resorting  to  an 
exploratory  thoracotomy  as  there  is  nowadays  in  submitting 
to  an  exploratory  laparotomy.  A  very  few  cases  have  been 
treated  in  this  way.^  The  writer  himself  has  had  occasion  to 
advise  exploratory  thoracotomy  in  two  cases,  but  neither 
the  physicians  nor  the  lay  pubUc  are  as  yet  educated  up  to 
the  proper  point  of  view,  and  both  cases  preferred  to  die  of 
cancer  without  an  attempt  at  cure  or  relief.  But  even  in 
cases  far  advanced,  where  there  is  apparently  no  hope  what- 
ever and  death  seems  imminent,  a  thoracotomy  may,  under 
certain  conditions,  be  indicated.  It  is  obvious  that  no  one 
would  think  of  operating  on  the  very  aged,  with  predominant 
brain  symptoms,  or  in  any  case  where  the  lung  symptoms 
are  more  or  less  in  the  background;  but  a  thoracotomy,  with 
a  possible  resection  of  one  or  two  or  three  ribs,  by  draining 
off  continually  recurring  effusions,  by  the  decompressing 
effect  produced  thereby,  quite  similar,  in  fact,  to  the  opera- 
tions now  performed  for  brain  tumor,  may  give  reUef  and 
produce  euthanasia,  in  the  place  of  otherwise  unspeakable 
torture. 

In  conclusion,  the  writer  may  be  permitted  to  express  the 
hope  that  malignant  disease  of  the  lungs,  so  disastrous  in  its 
results,  may  perhaps  in  the  near  future  be  summarily  dealt 
with  in  its  incipiency,  or  at  least  modified  in  its  progress,  so 
as  in  some  measure  to  assist  in  diminishing  the  sufferings  of 
humanity.  The  writer's  ideal  hopes  will  be  fulfilled  if  this 
essay  contributes  in  ever  so  small  a  degree  to  this  result. 

1  Miiser,  Table  I,  No.  208;  Benda,  loc.  cit.,  and  a  few  others. 


APPENDICES 


Carcinoma  —  Duration 

Not  stated   226 

No  autopsy    1 

Doubtful 1 

"Several  years"    1 

6  years    2 

4  years    2 

3  years    1 

2|  years    2 

2  years    7 

1^  years    6 

1^  years    3 

1  year  16 

11  months 1 

10  months 7 

9  months 9 

8  months 4 

7  months 9 

6  months 15 

6^  months 4 

6  months 11 

4|   months 1 

4  months 4 

3|  months 1 

3  months 15 

2|  months 2 

2  months 10 

"Several  months" 1 

li  months 5 

5  weeks 3 

3  weeks 2 

2  weeks 2 

374 


B 

Sarcoma  —  Duration 

Not  stated   48 

6  years    1 

3\  years    1 

3  years    2 


Between  2  and  3  years 1 

2f  years    1 

2  years    2 

22  months 1 

16  months 1 

15  months 1 

1  year  4 

11  months 1 

10  months 2 

9  months  .- 2 

8  months 1 

6  months 2 

6  months 4 

4  months 4 

3^  months 1 

3  months 3 

21  months 1 

2  months 3 

1|  months 2 

1  month   _1 

90 


C 

Carcinoma 
METASTASES 
Lymph  Nodes 


Bronchial  lymph  nodes    117 

Mediastinal  lymph  nodes 45 

Tracheal  lymph  nodes 26 

Cervical  lymph  nodes 23 

Retroperitoneal  lymph  nodes  .  23 

Hilus  nodes 16 

Regionary  lymph  nodes 15 

Axillary  glands    15 

Mesenteric  glands 14 

Supraclavicular 13 

Peribronchial 6 

Inguinal  glands 3 

Posterior  mediastinal 2 

Peritracheal 2 

Clavicular 2 

110 


APPENDICES 


111 


Epigastric  glands 2 

Portal  glands 2 

Subclavicular 

Glands  of  neck 

Glands  of  chest  

Subdiaphragmatic  glands 

Substernal 

Perigastric    

Retrogastic 

Periaortic    

Thoracic  glands 

Peritoneal  glands 

Parotid  glands  

Lumbar 

Celiac    

"Lymph  nodes"  not  specified  . 

Liver   103 


Gall-bladder 

Left  Lung  . . 
Right  Lung  . 
Both  Lungs  . 
Root  Lungs  . 


1 

28 

22 

16 

2 


Pleura  

?5 

Pleura   

10 

Right  Pleura   

q 

Left  Pleura    

8 

Pericardium 

Heart  .  .                   

39 
0 

Left  Ventricle      

7 

Right  Ventricle 

?: 

Left  Auricle 

6 

Right  Auricle 

3 

Myocardium 

Interventricular  Septum  of 
Heart 

3 
3 

Origin  Aorta 

? 

Large  Vessels 

? 

Pulmonary  Veins 

'?, 

Lower  Cava 

1 

Both  Kidneys  

Left  Kidney    

32 
15 

Right  Kidney   

11 

Left  Suprarenal   

17 

Right  Suprarenal 

7 

Both  Suprarenale  

Spleen   

14 
17 

Capsule  Spleen   

1 

Pancreas  

6 

Thyroid 

1*;^ 

Brain  

?8 

11 

Dura  Mater   

Corpus  Striatum    

Cerebral  Hemispheres 

Hypophysis 

Medulla   

Cerebrum  

Spinal  Cord 

Nerves  (Left  Vagus)  . 


Peritoneum 

Intestines 

Ileum  

Diaphragm    

(Esophagus 

Stomach 

Pylorus  

Gastro-hepatic  Ligament  . . . 

Mediastinum    

Posterior  Mediastinum  .... 

Bladder  

Right  Testicle 

Uterus  

Ovaries (1  Left) 


Skin 

Left  Eye 

Left  Leg  

Finger-tip  .  . . . 
Tip  of  Nose  . . 
Nasal  Septum 


Skeleton 


"Bones"    

Skull  

Frontal  Bone 
Parietal  Bone 

Sternum  

Clavicle    

Chest  Wall  .  . 

Ribs 

Upper  Ribs  . . . 

1st  to  7th   

5th  rib 

6th  rib 

7th  to  8th 


Vertebrae  

Dorsal 

3d  dorsal 

7th  to  8th  dorsal 

3d  cervical 

7th  to  10th 

Lumbo-sacral  . . . 


10 
1 
1 
1 
1 
1 
2 
1 

7 
1 
1 
6 
3 
4 
1 
1 
4 
1 


112    PRIMARY  MALIGNANT  GROWTHS  OF  THE  LUNG 


Femur 

Right  Humerus 
Long  Bones  ,  . . 
Iliac  Fossa  .... 
Shoulder  Joint 


Muscles 

Intercostal  

Trunk 

Back  and  Abdomen 

Chest 

Back 

Not  Specified   

No  Metastases 

Metastases  not   Mentioned 

D 

Sarcoma 

METASTASES 

Lymph  Nodes 

Bronchial    

Mediastinal    

E-etroperitoneal 

Axillary 

Cervical 

Peribronchial 

Hilus 

Inguinal    

Posterior  mediastinal 

Regionary 

Mesenteric  

Infraclavicular 

Supraclavicular  

Retrobronchial 

"Lymph  nodes"    

Various 


Liver 


3 
1 
1 
1 
1 
2 
33 
57 


15 
10 
5 
5 
4 
3 
3 
2 


Right  Lung  

Left  Lung    

Side  not  Specified 


Pleura  

Pericardium  .  .  . 
Heart  Muscle  . 
Left  Ventricle 
Left  Auricle  . . 
Right  Auricle  . 
Auricles   


Brain  

Spinal  Dura  .  . . . 
Spinal  Cord  .  . . . 
Left  Recurrent 


Anterior  Mediastinum 

Diaphragm    

Hepato-duodenal  Ligament 

Pancreas  

Spleen   

Peritoneum 

QilSOPHAGUS 

Kidneys 

Right  Kidney   

Left  Kidney    


16 


Skin 

Lower  cava 

Vertebrse 

Right  iliac   

Left  shoulder 

Scapula ; . 

Ribs  (2,  3,  4) 

(9,  10,  11) 

Right  humerus 

Humerus  (side  not  stated)  . 


No  Metastases 

Metastases  not  Mentioned 


24 
15 


Note.  —  It  was  found  practically  impossible  to  classify  the  metastases  accord- 
ing to  a  uniform  system.  They  were,  therefore,  recorded  as  reported  by  the 
authors  and  grouped  as  nearly  as  feasible  according  to  the  various  organs  and 
tissues  affected. 


TABLES 


114 


TABLE   I 


Adleb 


Abler 


M 


66 


LUNG     IN- 
VOLVED 


M 


Adleb 


4  Abler, 
I     Packard,  M., 

Med.  News,  Feb.  18, 
1906 


M 


67 


R 


67 


M 


Adleb 


55 


R 


M 


26 


R 


CLINICAL    SYMPTOMS 


Admitted  to  hospital  in  moribund 
condition  with  symptoms  interpreted 
as  pulmonary  phthisis.  No  history 
obtainable 


In  hospital  for  3  weeks.  For  3 
months  cough  and  pain  in  right  chest. 
Progressive  loss  of  strength  and  flesh, 
anorexia  and  nausea.  Flatness  and 
absence  of  voice  and  breathing  over 
greater  part  of  right  lung.  800  c.c.  of 
bloody  serum  aspirated  from  right 
pleura.  Irregular  fever  up  to  102. 
Acetone  in  urine.  Haemoglobin  65; 
reds  4,500,000;    whites  15,000 

No  heredity.  Inveterate  smoker. 
Stout,  healthy-looking.  Harassing 
cough,  pain  in  left  upper  chest, 
dyspnoea  on  slight  exertion.  For 
several  years  repeated  profuse  haemop- 
tysis. Flatness,  absence  of  voice  and 
breathing  over  left  anterior  chest.  No 
fever.  Sudden  death  from  profuse 
haemoptysis.  Approximate  duration 
of  disease  about  4  years 


No  heredity.  For  6  years  cough 
and  pain  in  right  chest.  Had  periods 
where  cough  and  pain  would  disappear. 
For  2  years  cough  permanent  a,nd 
more  harassing;  gradually  increasing 
dyspnoea.  Veins  over  chest  and  upper 
abdomen  enormously  dilated  and 
tortuous.  Complete  flatness,  absence 
of  voice  and  breathing  over  anterior 
right  chest.  No  bulging.  Occasional 
profuse  haemoptysis.  Haemoglobin  62 ; 
red  cells  3,980,000;  white  cells  14,300; 
lymphocytes  24%.  Later  enlarge- 
ment of  axillary  and  supraclavicular 
lymph  nodes.  600  c.c.  clear  serum 
aspirated  from  right  pleura.  Death 
in  a  hansom-cab  from  haemoptysis 

Father  died  of  cancer  of  stomach. 
Patient  always  in  good  health  until 
about  I2  months  before  admission. 
Pain  in  right  chest;  no  cough;  no 
expectoration.       Increasing    debility. 


CARCINOMA 


115 


AUTOPSY    NOTES 


Scant, 
muco- 
punilent, 
at    times 
bloody, 
no  tuber- 
cle bacilli 
or  tumor 
elements 


Muco- 
purulent, 
some- 
times 
bloody 
for  weeks, 
no  tuber 
cle  bacilli 
or  tumor 
elements 


None  at 
first,  then 
muco- 
purulent 
and  re- 
mains 
bloody; 
no  tuber- 
cle bacilli 
or  tumor 
elements 


None 


Heart  dislocated  to  right; 
right  lung  normal.  Sanguin- 
olent  effusion  in  left  pleura; 
pleura  much  thickened.  In 
upper  left  lobe  a  tumor  size 
of  two  fists  with  cavity  in 
centre 


Medullary  carcinoma 


METASTASES 


Region- 
ary  lymph 
nodes,  liver, 
both  kidneys 
and  spleen 


Large  tumor  involving 
upper  portion  of  lower  and 
lower  portion  of  upper  lobe 
of  left  lung,  containing  an 
irregular  cavity  filled  with 
blood  and  broken  down 
tumor  material,  and  into 
which  stumps  of  vessels  and 
bronchi  infiltrated  with 
tumor  material  still  project. 
The  rest  of  left  lung  diffusely 
infiltrated  with  tumor  along 
the  track  of  the  bronchial 
ramifications 

Tumor  of  the  right  main 
bronchus  extending  to  the 
posterior  portion  of  the  left 
bronchus.  Tumor  pene- 
trates the  right  lung  in  all 
directions  to  the  pleura 
along  the  track  of  the  bron- 
chial ramifications.    Numer- 

i  bronchiectatic  dilata- 
tions. Compression  of  upper 
cava,  right  pulmonary  and 
right  innominate  arteries 


Right  pleural  cavity  com- 
pletely filled  with  huge 
masses  of  old  fibrinous  blood 
clot,  and  entire  lung  pushed 
against  posterior  chest  wall 


Pericar 
dium,    heart 
muscle,  kid 
neys,  left 
suprarenal, 
bronchial 
and  medias- 
tinal   lymph 
nodes 


Pericardium, 
bronchial, 
mediastinal, 
and  retro- 
peritoneal 
lymph  nodes 
and  liver 


MICROSCOPE 


Medullary 
carcinoma 


Pleural 
surface  of 
right  dia- 
phragm, 
pericardium, 
regionary 
lymph  nodes 
and  left  lung 


It   was   practically 
impossible   in   micro- 
scopic  examination 
of  the  main  tumor  in 
the  left  lung  to  say 
whether    we    had    to 
deal  with  a  round- 
celled   sarcoma   or 
with  a  carcinoma. 
Only  the  study  of  the 
metastases  made  the 
diagnosis     of      carci- 
noma absolutely  cer- 
tain 


Typical  car- 
cinoma  of 
glandular 
type 


Epithelioma 


Right 
auricle,   cer- 
vical, medi- 
astinal, and 
bronchial 


116 


TABLE   I 


Adleb 


Adleb, 

Garbat,  A.  L., 
American  Joum.  of 
Med.  Sciences,  1909, 
Vol.  cxxxvii,  p.  857 


Adleb 


Allan,  Geo.  A., 

Lancet,  Oct.  6,  1907, 
p.  961 

Primary  Cancer  of 
Left    Bronchus   with 
Unusual  Associa- 
tion    of     Pressure 
Symptoms:  Sec-_ 
ondary  Growth  in 
Thyroid     and    Lym- 
phatic Glands 


BEX       AGE 


M 


M 


M 


M 


63 


63 


52 


38 


LUNG     IN- 
VOLVED 


R 


R 


R 


CLINICAL    SYMPTOMS 


Subsequently  hoarseness,  swelling  of 
right  side  of  face,  right  chest,  arm, 
and  foot.  Impaired  respiratory  motion 
of  right  chest.  Flatness  over  right 
chest  except  a  rather  large  area  pos- 
teriorly where  there  is  increased  vocal 
fremitus  and  some  tympany  on  per- 
cussion. Heart  8  cm.  beyond  left 
mammillary  line.  Irregular  areas  of 
bronchial  breathing  and  dulness  on 
left  chest.  Tyrnpanitic  area  in  right 
chest  steadily  diminishes  in  size 

No  heredity.  Harassing  cough  with 
profuse  mucopurulent,  sometimes 
bloody  expectoration  for  some  years. 
Lately  loss  of  weight  and  strength. 
Pain  and  slight  dyspncea  on  exertion. 
Complete  flatness,  diminished  voice 
and  breathing  sounds  to  4th  rib  on 
right  side.  Diagnosis  of  tumor  during 
life 

Loss   of   weight   for   over   a   year. 

Cough,  hoarseness,  night  sweats. 
Impaired  respiratory  motion  of  right 
chest  with  diminished  voice  and 
breathing  anteriorly,  flatness  pos- 
teriorly. In  November  150  c.c.  bloody 
serum  withdrawn.  No  characteristic 
elements.  6  weeks  later  increasing 
dulness,  high  fever.  Aspiration  60 
c.c.  chocolate-colored  pus.  Thora- 
cotomy. 6  weeks  later  cholecystitis; 
3  stones  removed  by  cholecystotomy. 
6  months  later  soft  tumor  over  right 
scapula;  tumor  excised;  carcinoma. 
Increasing  weakness;    death 

Uncertain  history  of  malignancy  in 
family.  Always  healthy;  no  syphihs. 
For  2  months  spitting  of  blood  in  the 
morning.  Increasing  cough.  Slowly 
diminishing  weight  and  strength  at 
first;  later  rapidly  diminishing  weight 
and  strength.  Increasing  pain  in  up- 
per right  chest;  dulness  over  right 
upper  lobe;  diminished  breathing  and 
respiratory  motion.  2  weeks  before 
death  signs  of  cavity  in  apex. 

No  previous  history;  no  syphilis. 
DoulDtful  heredity.  Pain  in  left  chest 
radiating  into  shoulder  and  down  left 
arm.  Increasing  loss  of  strength  and 
weight;  dyspnoea  on  slight  exertion. 
Hoarseness;  harassing  cough.  Flat- 
ness over  greater  portion  of  left  chest 
in  front  and  behind,  with  absence  of 
voice  and  breathing,  but  distinct 
transmission  of  heart  sounds  every- 
where. No  rales.  Right  chest  nor- 
mal. Hard  mass  above  left  clavicle. 
Enlarged    nodes    in    left    neck    and 


CARCINOMA 


117 


Mucopuru- 
lent, fre- 
quently- 
bloody, 
no  tuber- 
cle bacilli 


Profuse, 
purulent, 
bloody, 
no  tuber- 
cle bacilli, 
no  tumor 
cells 


No    tuber- 
cle bacilli, 
but  very 
numer- 
ous large 
"Korn- 
chenzel- 
len"(Len- 
hartz) 


Never 
bloody, 
no  tuber- 
cle bacilli 


AUTOPSY    NOTES 


and  compressed.  Anterior 
half  of  right  lung  completely 
replaced  by  tumor.  Right 
auricle,  pulmonary  artery, 
and  upper  cava  compressed 
by  tumor.  There  are  throm- 
boses reaching  into  the  right 
internal  jugular  and  sub- 
clavian arteries 


Confirmed    diagnosis. 
Records   could   not   be   ob- 
tained 


Right  pleura  and  dia- 
phragm thickened  and  ad- 
herent. Middle  and  lower 
lobe  almost  entirely  replaced 
by  tumor.  Bronchiectatic 
dilatations 


Cavity  in  right  apex  sur^ 
rounded  by  tumor  extending 
along  bronchial  vessels  to 
the  hilus  and  to  the  pleura 
Gray  hepatization  around 
the  tumor 


Clear  serum  in  right 
pleura.  Cancer  encircling 
left  main  bronchus  from  bi- 
furcation downward  and 
obstructing  its  lumen.  Bron- 
chiectatic abscesses;  throm- 
bosis of  left  subclavian  vein 
Degeneration  of  left 
recurrent 


METASTASES 


lymph 
nodes 


Both  lungs, 
liver,  bron- 
chial and 
retroperito- 
neal lymph 
nodes 


Right 
pleura ;   su- 
praclavicu- 
lar gland 


Bronchial 
and  medias- 
tinal lymph 
nodes,  left 
pleura,  peri- 
cardium, 
and  left  lobe 
of  thyroid 


MICBOSCOPE 


Cylindrical- 
celled  carci- 
noma. Un- 
doubted ori- 
gin from  bron- 
chial mucous 
glands 


Squamous 
carcinoma 
probably 
originating 
from  small 
bronchus 


Scirrhus 
with  unusua- 
ly  large  cells 
having  ten- 
dency to  ne- 
crosis 


118 


TABLE   I 


10 


11 


Anderson,  J.  W., 
Glasgow  Med.  Jour., 
1883,  146-148 


Angelhoff, 
..  Diss.  Miinchen,  1905 
tjber    das   primare 
Lungencarcinom 


12 


13 


14 


M 


Antze, 

Diss.  Kiel,   1903 
(After  Angelhoff) 

ijber  primaren   Lun- 
genkrebs 


Aknal, 

Gaz.    des    H6pitaux 

1844,  p.  78 
Cancer    gpitheloide    du 

Thorax,  etc. 


ASCHENBORN,  M 

Arch,  f .  Klin.  Chirur., 
1880,  171 


M 


LUNG     IN- 
VOLVED 


66 


75 


M 


40 


R 


R 


64 


12 


R 


R 


CLINICAL    SYMPTOMS 


axilla.  Intermittent  fever  up  to  103. 
Paralysis  of  left  recurrent;  left  pupil 
contracted;  slight  ptosis  of  left  eyelid. 
Local  hyperhidrosis  of  right  face  and 
head.  Death  5  months  after  first 
definite  symptoms 

Severe  dyspnoea.  CEdoema  of  upper 
part  of  body,  including  face,  chest,  and 
both  arms.  Superficial  veins  dilated. 
Slight  cough  and  expectoration.  No 
fever.  Dulness  on  right  chest  from 
clavicle  to  nipple;  both  bases  dull, 
with  diminished  respiration  and  voice 


For  3  months  cough,  expectoration, 
dyspnoea;  some  fever.  Pain  in  left 
chest;  night  sweats.  Increasing 
emaciation;  impaired  respiratory  mo- 
tion of  left  chest.  Dulness  to  5th 
spinous  process  posteriorly;  bronchial 
breathing;  a  few  rales.  Flatness  and 
loss  of  breathing  and  voice  at  base. 
Bloody  serum  removed  several  times 
by  aspiration.  Clinical  diagnosis:  pul- 
monary phthisis 

Cough,  expectoration,  pain,  jaun- 
dice. No  dulness.  Temporary  im- 
provement. After  1  year  dulness  over 
whole  right  lung;  tjonpanitic  percus- 
sion note  and  amphoric  breathing  at 
right  base.  Some  fever.  _  Intense 
pain  and  dyspnoea.  Clinical  diag- 
nosis: phthisis  and  gangrene  of  right 
lung 


While  in  perfect  health  sudden  chill, 
fever,  sore  throat,  cough  and  symptoms 
of  bronchitis,  diagnosed  as  influenza. 
Soon  after  dyspnoea,  aphonia,  stenotic 
respiration  to  right  of  sternum.  Loss 
of  breathing  sounds  over  lower  lobe, 
but  normal  percussion  note.  Left 
lung  normal.  Later  oedoema  of  face, 
neck,  and  arms ;  dilatation  of  veins  of 
right  chest  and  abdomen.  Subse- 
quently effusion  in  right  _  chest  and 
oedoema  of  lower  extremities.  A  few 
days  before  death  respiratory  murmur 
is  again  heard  over  lower  right  lung. 
Sudden  death.  Duration  of  disease 
about  9  months 

Sick  more  than  2  years.  Right 
chest  expanded  by  tumor  pushing 
heart  to  left  and  liver  downward. 
Flatness,  absence  of  breathing  sounds, 
extreme  dyspnoea,  cyanosis,  and  ca- 
chexia 


CARCINOMA 


119 


SPUTUM 

AUTOPSY    NOTES 

METASTASES 

MICROSCOPE 

BEMARKS 

No  details 

Fluid  in  both  pleurse.  Tu- 
mor at  root  of  right  lung. 
Compression  of  upper  cava 

No  details 

Not  given 

Author  says: 
"Tumor   is  probably 
sarcoma,    originating 
from  bronchial  glands 
at  root."    This  seems 
doubtful;  more  prob- 
ably a  bronchial  car- 
cinoma 

Mucopuru- 

Bloody fluid  in  left  pleura. 

No  details 

Alveolar 

lent,  no 

Whole  left  lung    retracted 

structure. 

bacilli 

and     compressed ;    studded 
with  tumor  nodules.     Bron- 
chi  filled    and    surrounded 
with    similar   tumors.     Tu- 
mor nodules  over  costal  and 
pulmonary  pleura  and  dia- 
phragm 

voluminous 
stroma,  poly- 
morphous 
and  typical 
cylindrical 
epithelial 
cells;  areas  of 
glandular  ar- 
rangement 

Not  stated 

Cancer  of  right  main 

Bronchial, 

Alveolar 

bronchus  and  its  branches. 

mediastinal, 

structure,  ori- 

Chronic    pneumonia      and 

cervical,  and 

gin  from  sur- 

bronchiectases; gangrene  of 

retroperito- 

face epithe- 

lung;   compression  of  upper 

neal  lymph 

ium  of  main 

cava 

nodes.    Per- 
foration of 
cancerous 
lymph 
nodes  into 
oesophagus 

Dronchus 

Bloody 

Serious   effusion  in   right 

Right  lung. 

Not    given 

Probably    carci- 

pleura.       Tumor    in    right 

bronchial. 

noma  of  bronchus  of 

lower  lobe  with  cavity  in  its 

mediastinal. 

right  lower  lobe 

centre.     Right  main   bron- 

and cervical 

chus   obstructed    by  larda- 

lymph  nodes 

ceous  neoplasm,  also  bron- 

and right 

chus   of  lower  lobe   almost 

kidney 

completely  occluded.    Com- 

pression of  upper  cava  and 

recurrent  laryngeal 

Not  stated 

Entire  right   lung  except 
a    small    remnant    at    apex 
converted  into  tumor,  erod- 
ing   several    ribs.      Tumor 
contains  several  large  cysts 
filled  with   dark  fluid.     Ev- 

None 

Not  given 

Tumor     is     called 
cysto-carcinoma    of 
lung 

erything  else  in  body  normal 

120 


TABLE   I 


15 


16 


AUFRECHT, 

Nothnagel  Handbuch 
d.  Spec.  Path.  u. 
Therapie,   Vol.  XIV, 
1st  Ed.,  1899,  p.  370  ff. 
Das  Lungencarcinom 

Loc.  err. 


17 


Loc.  CIT. 


18 


19 


AtTGIEH,  G.  AND 

Desplats,  N., 
Journ.  de  Soc.  Med 
de  Lille,  1883 


AirVAED, 

Biillet.  Soc.  Anat.  de 
Paris,   1882,   9&-99 


M 


M 


M 


M 


M 


65 


58 


LUNG     IN- 
VOLVED 


R 


46 


69 


56 


R 


R 


20 


21 


Bargtjm, 

Diss.  Kiel,  1897 

Ein  Fall  von  primarem 
Krebs  der  Trachea 
und  des  rechten  Bron- 
chus 


Baeth,  H. 

Le  Bull.  M6d.  Paris, 
1902,  Vol.  XVI,  Pt 
2,  p.  757 


62 


37 


R 


clinical  symptoms 


Dulness  over  right  middle  and  lower 
lobe.  Diminished  breathing;  loss  of 
fremitus.  No  fever.  Nutrition  good. 
Dyspnoea  on  exertion.  Aspiration 
negative.  Increasing  weakness.  Dura- 
tion of  disease  14  weeks 

Father  died  of  cancer  of  stomach. 
Patient  always  healthy.  Commenced 
with  cough  and  dyspnoea;  later  effu- 
sion in  left  pleura.  Aspiration  2300 
c.c.  bloody  serum;  breathing  becomes 
better;  dulness  remains.  Sudden 
death  from  pulmonary  oedoema.  Dura- 
tion about  1  year.  Clinical  diag- 
nosis: pleurisy 

For  8  months  "  inflammation  of  lung 
and  pleura."  For  4  months  dysp- 
noea. On  admission  immediate  resec- 
tion of  ribs  with  discharge  of  3000  c.c. 
of  pus  from  right  pleura.  No  relief 
after  operation.  Increasing  stridor  and 
dyspnoea.  No  fever.  Enlargement 
of  supraclavicular  glands.  Tumor 
size  of  apple  in  liver.  Paralysis  of 
right  vocal  cord.  Death  26  days  after 
operation.  Diagnosis  made  during 
life 

Fever,  dyspncEa,  dysphagia,  pain 
in  chest.  Flatness  to  3d  interspace; 
absence  of  breathing 


Sick  5J  months.     Dyspnoea,  pain  in 

left  chest.  Dulness  over  entire  left 
side.  Diminished  fremitus;  absence 
of  breathing  at  base ;  further  up  harsh 
bronchial  respiration.  Heart  dis- 
placed toward  right.  No  cachexia. 
Later  anorexia;  some  fever  toward 
evening.  Chest  aspirated  without 
result.  Later  cedoema  and  albuminuria 

No  heredity.  6  weeks  after  re- 
covery from  some  acute  disease  with 
cough  and  fever,  swelling  of  face  and 
neck,  later  of  chest.  Dyspnoea  and 
cough  especially  after  eating.  Cyano- 
sis. Area  of  dulness  with  diminished 
voice  and  breathing  over  right  lower 
chest.  Nothing  else  on  lungs.  Some 
effusion  in  right  pleura 


Small,  poorly  nourished  woman. 
Repeated  attacks  of  bronchitis.  Pres- 
ent illness  began  only  5  days  before 
admission  with  cough,  fever,  and  chill. 


CARCINOMA 


121 


AUTOPSY    NOTES 


METASTASES 


MICROSCOPE 


Mucopu- 
nilent, 
mixed 
with 
blood 


Not  stated 


Occasion- 
ally 
bloody 


Bloody 


Not  stated 


None 


Abundant,' 
purely 
mucous, 
no  blood. 


Diffuse  medullary  carci- 
noma in  lower  portion  mid- 
dle lobe 


Left  lower  lobe  converted 
into  a  firm  tumor  in  which 
only  the  larger  bronchi  can 
be  distinguished;  centre 
broken  down 


Carcinoma  probably  of 
right  main  bronchus  ob- 
structing trachea  and  bron- 
chus 


Mediastinal 
lymph  nodes 


Liver 


Not  given 


Not  given 


Mediastinal 
and  tracheal 
lymph  nodes 
and  liver 


Not  given 


Upper  right  lobe  almost 
completely  replaced  by  soft 
cheese-like  tumor.  Pleura 
thickened;  bronchi  com- 
pressed. Remainder  of 
right  lung  pneumonic  hepa- 
tization 

Entire  left  lung  one  mass 
of  white  encephaloid  tumor 
containing  many  cavities. 
Granulated  tumor  on  peri- 
cardium 


Beginning  of  right  main 
bronchus  and  wall  of  trachea 
infiltrated  with  tumor.  Sec- 
ondary bronchus  also  oblit- 
erated by  tumor.  Bronchi- 
ectatic  cavities  in  right  lower 
lobe.  Compression  of  right 
jugular,  innominate,  and  ax- 
illary veins,  also  upper  cava. 
Abundant  effusion  in  right 
pleura 

Right  lung  healthy  except 
old  and  healed  tubercular 
foci  in  apex.  Left  pleura 
adherent  and  whole  left  lung 


Bronchial 
and  tracheal 
lymph  nodes 


Mediastinal 
and  bron- 
chial lymph 
nodes 


Regionary 
lymph  nodes 


Not  given 


Tumor  sim- 
ply desig- 
nated as 
encephaloid 
cancer 


No  details 


Tumor  simply  des- 
ignated as  cancer 


Absolutely 
not  a  second 
ary  deposit 
throughout 


Alveolar 
structure ; 
polymor- 
phous epithe- 


Remarkable  points 
about    this    case    are 
the  pleurisy  with 
little     effusion,     the 


122 


TABLE   I 


Cancer  primitif  oblit6- 
rant  de  la  grosse 
bronche  gauche; _ 
Bronchopneumonie 
tuberculeuse  du  Pou- 
mon  correspondent 


22 


23 


"24 


26 


Beale, 

Med.  Times  &  Gaz., 
London,  1869,  II,  382 


Beattftim^, 

Bull,  et  M6m.  de  la 
Soc.  Anat.  de  Paris, 
1902,  Jom.,  IV,  No.  7, 
p.  664 

Cancer  massif  primitif 
du  Poumon  avec  Le- 
sions multiples 

Beck,  Hugo, 

Zeitschr.     f.     Heilk., 

Vol.  V,  1884,  p.  459. 

(Path.  Festschrift, 

Prag) 
Zur  Kenntniss  des  pri- 

mS,ren  Bronchialkreb- 


Log.  ciT. 


M 


M 


41 


Not 
stated 


67 


LUNG     IN- 
VOLVED 


R 


R 


M        65 


R 


CLINICAL    SYMPTOMS 


4  days  before  admission  pain  in  left 
chest.  On  examination  impaired  res- 
piratory motion  of  left  chest;  slight 
dulness  at  base ;  feeble  respiration  and 
pleuritic  friction.  Fine  rales  over 
whole  of  chest.  Fever  up  to  40°  C. 
Diagnosed  as  grippe  (which  was  then 
epidemic)  with  pleuritic  complications 
and  the  possibility  of  tuberculosis. 
Next  day  everything  improved  except 
left  lung,  which  remained  the  same. 
Puncture  over  left  chest  withdrew 
clear  serum  without  tumor  elements, 
tubercle  bacilli,  blood,  or  lymphocytes. 
Later  severe  pain  over  left  nipple, 
intense  dyspnoea,  high  fever,  diarrhoea, 
and  vomiting.  Later  series  of  severe 
chills  and  hectic  fever.  About  month 
after  admission  retraction  of  left  chest, 
marked  dyspnoea,  much  cough,  rapid 
emaciation.  Later  absolute  absence 
of  voice  and  breathing;  flat  percus- 
sion note;  later  cyanosis  and  signs 
of  cavity  in  left  upper  lobe.  Death 
about  3  months  after  admission  to 
hospital 

Loss  of  flesh,  pain  in  left  chest, 
profuse  perspiration;  dry  cough.  Flat- 
ness over  left  chest;  no  fremitus. 
Heart  displaced ;  some  bulging  of 
lower  intercostal  spaces.  Dilatation 
of  superficial  veins.  Progressive  in- 
crease of  dulness ;  increasing  cachexia. 
Later  painful  secondary  tumor  in  left 
axUla 

Old  syphilitic  with  tertiary  lesions. 
Large  liver,  dyspnoea,  cachexia.  Bloody 
effusion  in  right  pleura.  Rapid  de- 
velopment in  3  months.  Clinical 
diagnosis:  cancer  of  liver  with  in- 
volvement of  lung  and  pleura 


No  details 


Clinical  diagnosis:    tumor  of  right 
pleura 


CARCINOMA 


123 


AUTOPSY    NOTES 


no  tuber-  consolidated  and  much 
cle  bacilli  smaller  than  normal.  Lower 
lobe  atrophic  and  retracted 
Blood  and  pus  flow  from 
trachea  on  taking  out  lung 
3  cm.  below  bifurcation  a 
round  soft  tumor  arises  from 
wall  of  left  main  bronchus, 
almost  completely  obstruct- 
ing bronchus.  The  whole 
left  lung  like  a  sponge  filled 
with  pus  is  a  series  of  small 
round  tumor  areas  sur- 
rounded by  lung  tissue  ap- 
parently not  much  altered  — 
some  solid  some  softened  and 
broken  down  in  centre,  alto- 
gether like  tubercular  foci. 
Bronchial  tumor  is  not  ul- 
cerated but  is  surrounded  by 
apparently  healthy  mucous 
membrane;  penetrates  down 
to  cartilage 


None 


No  details 


No  details 


No  details 


METASTASES 


the  entire 
body,  not 
even  bron- 
chial or  tra- 
cheal glands 


Entire  left  lung  occupied 
by  tumor;  only  a  thin  shell 
of  lung  tissue  remaining  be- 
hind and  at  base 


Liver  merely  congested. 
Cancer  right  lower  lobe. 
Aneurysm  of  descending 
aorta;     thrombosis     azygos 


Medullary  tumor  of  right 
main  bronchus  and  its  rami 
fications.  Bronchiectatic  di- 
latations and  lobular  pneu- 
monic consolidation  in  right 
lung,  also  some  tubercular 
granulations.  Upper  cava 
compressed  and  infiltrated 
by  tumor 


Cavity  in  right  upper  lobe, 
walls  infiltrated  with  cancer. 
Medullary  cancer  in  right 
main  bronchus  and  branches 
obstructing  lumen.  Neo- 
plasm extends  through  lung 
along  bronchial  ramifica- 
tions directly  into  cavity. 
Infiltration  and  compres- 
sion of  upper  cava  and  vena 
azygos 


Bronchial, 
retroperito- 
neal, and  su- 
praclavicu- 
lar lymph 
nodes,  axilla, 
and  pericar- 
dium 


Diaphragm, 
pericardium, 
and  medias 
tinal  lymph 
nodes 


Bronchial 

nodes  at 
hilus 


MICROSCOPE 


lial  cells. 
Origin  from 
bronchial 
mucous 
membrane. 
The  foci  in 
lung  are 
proven  to  be 
tubercular, 
consisting 
mainly  of  typ- 
ical tubercles 
in  all  stages 
of  develop- 
ment and 
degeneration 


complete  atelectasis 
of  lung,  and  the  tu- 
bercular afifection  of 
one  side  only 


No  details 


Right  bron- 
chial lymph 
nodes, 
pleura,  thy- 
roid, liver, 
both  supra- 
renals 


No  details 


Alveolar 
structure ; 
spindle  celled 
stroma 


Author  thinks 
tumor    spread    along 
bronchial  ramifica- 
tions    and    believes 
that  thoracic  duct 
was  involved 


Origin  from   bron- 
chial mucous  glands 


Alveolar 
structure ; 
large  epithe- 
lial cells  with 
frequent  mu- 
coid degener- 
ation 


Origin  from   bron- 
chial mucous  glands 


124 


TABLE   I 


NO. 

AUTHOR 

SEX 

AGE 

LTTNG     IN- 
VOLVED 

CLINICAL    SYMPTOMS 

26 

Begbie,  J.  Wahburton 
Archiv.  of   Med.,    II, 
London,    1860-61,  p. 
145 

Case  of  Mediastinal  and 
Pulmonary  Cancer 

M 

50 

R 

Always  healthy.  Cough,  husky 
voice,  intense  dyspncsa;  rapid  emacia- 
tion. (Edcema  right  face,  neck,  arm, 
and  over  upper  sternum.  Dulness  to 
2d  rib;  diminished  respiratory  motion 
and  fremitus.  Feeble,  stridulous, 
highly  bronchial  respiration.  Tap- 
ping of  chest  gave  temporary  relief. 
In  23  days  was  tapped  10  times,  total 
amount  of  clear  seruin  being  550 
ounces.  Duration  of  disease  about 
6  weeks 

27 

Behiee, 

Hop.  de  la  Petie,  Gaz. 
des  Hop.,  45,  1867 

F 

35 

R 

Cough,  headache,  vomiting,  fever. 
Emaciation,  intense  dyspnoea,  neural- 
gia in  right  arm.  Right  chest  3  cm. 
larger  than  left.  Dulness  with  tubular 
breathing  and  amphoric  voice  on 
right  upper  chest.  Enlarged  glands 
over  right  clavicle 

28 

Belcher,  W.  N., 

Brooklyn  Med.  Jour., 
Vol.  V,   1901,  p.  703 

Primary   Carcinoma   of 
the  Lung 

F 

47 

L 

Always  in  good  health  until  attack 
of  "grippe  pneumonia."  Effusion  in 
left  pleura;  aspiration  withdraws 
seropurulent  fluid.  Patient  improved, 
but  there  was  an  early  recurrence  and 
several  more  aspirations  were  neces- 
sary. One  week  before  death  a 
nodule  appeared  under  the  skin  on  the 
anterior  of  left  chest 

29 

Benkert, 

Diss.     Freiburg.     No 

date 
Das    primare    Lungen- 

carcinom 

M 

49 

R 

Pain  about  sternum;  increasing 
dyspnoea  and  cyanosis.  CEdoema  of 
upper  part  of  body,  especially  left 
arm.  Dilatation  of  veins  of  chest. 
Left  limg  normal.  Flatness  over 
upper  right  chest;  dulness  below. 
Bronchial  respiration.  Enlargement 
of  axillary  lymph  nodes 

30 

Benkeet, 
Loc.  cit 

M 

58 

R 

Burning  pain  in  right  arm  and  neck. 
Cyanosis  of  face,  ffidoema  of  neck  and 
both  arms.  Clubbed  fingers.  Dul- 
ness posteriorly  from  2d  dorsal  to 
angle  of  scapula.  Below  clavicle 
anteriorly,  bronchial  respiration 

31 

Benkert, 
Loc.  cit. 

M 

71 

L 

No  clinical  history 

CARCINOMA 


125 


AUTOPSY   NOTES 


METASTASES    MICROSCOPE 


None 


None 


No  details 


Bloody, 
contains 
spirals 
and  nu- 
merous 
large  epi- 
thelial 
cells 


No  tubercle 
bacilli, 
numer- 
ous epi- 
thelioid 
cells 


No  details 


Large  "  encephaloid  "  can 
cer  under  upper  f  of  ster- 
num involving  nearly  all  of 
right  upper  lobe  and  ob 
structing  main  bronchus. 
Compression  of  upper  cava 
and  large  thoracic  veins 


Irregular  nodular,  hard, 
white  tumor,  size  of  fist  in 
right  middle  lobe 


Bloody  fluid  in  left  pleura, 
thickening  of  left  pleura, 
pericardium,  and  left  half  of 
anterior  mediastinum  with 
hard  nodular  tumor  masses 
connecting  directly  with 
nodule  under  the  skin. 
Entire  anterior  left  lung 
infiltrated  with  hard  white 
tumor 

Bloody  serum  in  right 
pleura  and  in  pericardium 
In  mediastinum  a  tumor  ex- 
tending downward  to  the 
right,  which  involves  right 
upper  lobe.  Compression 
of  right  auricle;  thrombosis 
of  jugular  veins;  compres- 
sion of  innominate  and  sub- 
clavian, also  trachea 


No  details 


1000  c.c.  clear  serum  in  left 
pleura.  Right  apex  firmly 
adherent  to  ribs  by  tumor 
masses  which  extend 
through  lung  and  penetrate 
trachea  immediately  above 
bifurcation 

Upper  part  of  left  lung  ex- 
tremely soft  tumor,  nodu- 
lated with  fibrous  strands 
between  nodules.  Erosion 
of  2d  to  5th  dorsal  verte- 
brae by  neoplasm 


Right 
pleura, 
glands  of 
neck,  medi- 
astinal 
lymph 
nodes  com- 
pressing 
trachea 

Bronchial 
glands, 
pleura,  and 
pericardium 


"Distinct 
cancer  cells" 


Probably  bronchial 
carcinoma 


Axillary 
lymph 
nodes, 
tracheal, 
bronchial, 
mediastinal, 
and   mesen- 
teric lymph 
nodes. 
Pericardium 
left  supra 
renal.  Small 
nodule,  2  cm 
in  diameter 
in  ileum 

Tracheal 
and  bron- 
chial lymph 
nodes 


No  details 


Author 
states  that 
tumor  con- 
tains typical 
cancer  cells 


Scirrhus 
with  cuboidal 
cells 


Typical 
medullary 
carcinoma 


T3T)ical 
pavement 
epithelium 


No  details 


It  is  probable  that 
the  small  tvmaor  in  the 
ileum  was  primary 


126 


TABLE   I 


32 


33 


34 


35 


Benkeet, 
Log.  cit. 


Bennett,  J.  Hughes, 
Edinburgh,    1849,    p 
43 

Cancerous     and     Can- 
croid Growths 


Beenheim  and  Simon, 
Revue  M6d.  de  I'Est 
Nancy,  1886 


Bernstein,  A., 
Diss.  Miinchen, 
1909 

Zur  klinischen  Diag- 
nose    des     primaren 
Lungencarcinoms 


36 


37 


M 


M 


66 


45 


39 


53 


LUNG     IN- 
VOLVED 


R 


Betschaet, 

Vircho"ws    Arch.," 

..  142,  1895 

Uber  die  Diagnose 
mahgner  Lungentu- 
moren  aus  dem  Spu- 
tum 


Bevacqua,  a., 

Giornale  internazio- 
nale  delle  Scienze  Me- 
diche,  1904,  p.  625 

Sul  Carcinoma  cilin- 
drico  primitive  del 
Pulmone 


M 


54 


39 


R 


R 


CLINICAL  STMPTOM8 


No  clinical  history 


Pain,  dry  cough,  dyspnoea.  Left 
chest  less  voluminous  than  right. 
General  dulness  over  left  chest.  Flat- 
ness below  clavicle.  At  apex  bronchial 
respiration;  below  faint  and  dimin- 
ished. Increasing  emaciation  and 
cachexia 

Pain,  radiating  into  arm  and  back. 
Dyspnoea;  effusion  in  right  chest. 
By  aspiration  2000  c.c.  of  clear  serum; 
smaller  quantities  are  subsequently 
aspirated,  later  becoming  hsemorrhagic 


History  of  lues  and  urinary  troubles. 
Well  until  5  years  before  admission, 
when  urinary  difficulties  began.  Three 
weeks  before  admission  painful  mictu- 
rition, feeling  of  great  weakness, 
fever,  much  cough,  stabbing  pain  in 
chest,  mmabness  in  both  hands. 
Right  apex  slightly  dull;  many  rales. 
Later  dulness  left  base  with  diminished 
respiration.  Albumin  in  urine.  Clini- 
cal diagnosis:  tabes  dorsalis,  phthisis 
pulmonalis;  neoplasm.  Death  about 
5  weeks  after  admission 

No  clinical  history 


No  heredity.  Slight  dulness,  in- 
creased vocal  fremitus  and  some  moist 
rales  in  right  subscapular  region.  All 
the  rest  of  lung  normal.  No  fever; 
very  little  cough  at  first.  History  of 
syphilitic  infection.  Pain  for  about 
a  year,  particularly  in  arms,  head,  and 
tibiae.  Increasing  cough_  and  expec- 
toration; fever  and  night  sweats. 
Pain  at  right  base;  signs  of  cavity  in 
lung.  Diarrhoea.  Clinical  diagnosis: 
tuberculosis 


CARCINOMA 


127 


BPUTTJM 

AUTOPSY  NOTES 

METASTASES 

MICROSCOPE 

REMABE3 

No  details 

Tumor  at  hilus  of  left  lung 

Lymph 

Pavement 

Author  considers 

adherent     to    pericardixmi. 

nodes 

celled  carci- 

the   alveolar    epithe- 

Right lung  normal 

noma 

lium  the  starting 
point  of  the  main  tu- 
mor in  the  last  3  cases 

No  details 

Upper     left     lobe     dense 
yellowish-white   tumor  size 
of  a  large  orange.     Isolated 
nodules  of  cancer  in  left  lung 
surrounding  large  bronchial 
tubes.      Heart,   right    lung, 
and  all  other  organs  normal 

Bronchial 
glands  and 
pericardium 

No  details 

One  small 

Chocolate  colored  fluid  in 

Left  pleura 

Merely 

hgemop- 

right    pleura.     Right    lung 

and  perito- 

stated that  it 

tysis 

infiltrated   throughout  with 

neum,    both 

is  medullary 

firm,    white   tumors;    bron- 

of  which  are 

cancer 

chiectatic  dilatations 

studded 
with  small 
nodules  like 
tubercles 

Abundant, 

Simply  says  carcinoma  of 

Left  peri- 

Carcinoma 

mucoid, 

left  lower  lobe.    A  typical 

bronchial 

simplex  (sic) 

no  tuber- 

catarrhal hsemorrhagic 

glands  and 

originating 

cle  bacilli 

pneumonia 

in  liver 

from  bron- 
chial mucous 
membrane 

Sputum 

Cancerous  infiltration  of 

Right  upper 

Cylindrical 

Bronchial     surface 

contained 

right  lower  lobe ;  also  a  sep- 

lobe and 

celled  carci- 

epithelium  stated  aa 

numerous 

arate    nodule    not    sharply 

corpus  stri- 

noma 

starting  point 

epithelial 

bounded.  Lymphatics  large- 

atum of  the 

cells  from 

ly  injected  with  tumor 

brain 

which  di- 

masses 

agnosis 

of  tumor 

was  made 

during 

life 

At  first 

Left   lung   normal;  right 

Bronchial, 

TjT)ical  cylin- 

scant, 

lung  adherent;  grayish  infil- 

subclavicu- 

drical celled 

later 

tration    in    centre    of  lower 

lar  glands 

carcinoma. 

abund- 

lobe   in    which    pulmonary 

and  kidneys 

which  author 

ant,  never 

structure  is  no  longer  dis- 

considers as 

tubercle 

cernible.     Cheesy     deposits 

originating 

bacilli 

broken    down   and   forming 
cavities  surrounded  by  nu- 
merous     miliary      nodules. 
Bronchial   glands  enlarged; 
contain     cheesy      deposits, 
miliary  nodules;    some  dif- 
fusely infiltrated.     Anatom- 
ical diagnosis :   tuberculosis 
of  bronchial  glands  of  lower 

from  bron- 
chial mucous 
membrane 

128 


TABLE   I 


NO. 

ATTTHOB 

SEX 

AGE 

LUNG  IN- 
VOLVED 

CLINICAL   SYMPTOMS 

38 

Beveeidge, 

Medical  Press  &  Cir- 
cular, June  2,  1869 

Case  of  Sudden  Death 

M 

64 

R 

Slight  cough;  pressure  over  chest. 
Able  to  work  until  death.  Sudden 
death  from  haemoptysis 

39 

BiRCH-HlRSCHFELD, 

Arch.    f.    Heilkunde, 

19,  1878 

(after  Reinhard) 

M 

50 

R 

Cough,  dyspnoea,  weakness  and  ema- 
ciation; insomnia.  Dulness  over  right 
upper  lobe  ;  rough  breathing  in  front; 
bronchial  breathing  behind  right  upper 
lobe ;  rales.  CEdoema  and  dilated  veins 
of  upper  part  of  body.  Glands  over 
both  clavicles  enlarged  to  size  of  fist. 
Left  lung  normal 

40 

Blumenthal, 
Diss.  Berlin,  1881 
(quoted  after  Fuchs) 
Zwei  Falle  von  pri- 
maren  malignen  Lun- 
gentumoren 

M 

25 

L 

Repeated  haemoptysis;  increasing 
dyspnoea.  Gradually  increasing  dvil- 
ness  over  whole  of  left  lower  lobe  with 
bronchial  respiration  and  increased 
vocal  fremitus;  later  bulging  of  left 
lower  chest.  _  First  aspiration  no  fluid ; 
later  aspiration  effusion  which  later 
becomes  bloody  and  under  the  micro- 
scope contains  tumor  particles.  Fre- 
quent aspirations  become  necessary; 
repeated  attacks  of  haemoptysis 

41 

Borx,  Emile, 

Soc.   Anatomique   de 
Paris,  1891,  p.  398 

Cancer  primitif  du  Pou- 
mon  gauche,  etc. 

F 

59 

L 

No  previous  history.  Patient  on 
admission  pulseless;  cedoema  of  lower 
limbs;  arrhythmia.  Extensive  peri- 
cardial dulness;  flatness  and  absence 
of  voice  and  breathing  over  both  sides 
of  chest  posteriorly 

42 

BOTESATO, 

Diss.  Berlin,  1863 

De    Carcinomate    Pul- 

monum  et  Pleurae 

F 

43 

L 

For  5  years  dyspncsa  and  palpitation 
on  slight  exertion ;  more  recently  ema- 
ciation and  weakness,  increasing  dysp- 
noea, and  severe  pain  in  left  chest.  Dul- 
ness and  impaired  respiratory  motion 
over  whole  of  left  chest;  bronchial 
breathing  over  upper  portion;  dimin- 
ished voice  and  breathing  over  lower 
portion.  Right  lung  normal.  Mitral 
regurgitation.  2000  c.c.  bloody  fluid 
aspirated  from  left  chest 

43 

B6TTGEH, 

Miinch.  med.  Woch., 
1902,  p.  272 
Ein  Fall  von  primarem 
Lungencarcinom 

M 

68 

R 

Oppression  in  right  chest  soon  fol- 
lowed by  cough,  pain,  fever.  Right 
lower  base:  dulness,  rales,  diminished 
breathing.  Diagnosis  influenza.  Six 
months  later  increased  dulness  involv- 
ing the  entire  lower  lobe  posteriorly; 
slight  bulging  appears ;_  impaired  res- 
piratory motion,  diminished  fremitus. 
Progressive  loss  of  strength  and  weight. 
Increasing  dyspnoea,  cachexia  and  pain. 
Death  about  2  years  after  first  com- 
plaint 

CARCINOMA 


129 


AUTOPSY    NOTES 


METASTASES 


MICROSCOPE 


Not  men- 
tioned 


Moderate, 
occasion- 
ally 

streaked 
with 
blood 


Repeated 
hsemop- 
tysis 


Not  men- 
tioned 


Scant 


Scant,  mu- 
coid, 
occa- 
sionally 
bloody; 
later 

raspberry 
jelly,  no 
tubercle 
bacilli;    a 
little 

later  elas- 
tic fibres 


lobe  of  right  lung;  tubercU' 
lar,  possibly  syphilitic  nod' 
ules  in  kidneys 

Two  tumors  in  right  lower 
lobe  size  of  a  hazel  nut,  one 
of  which  ulcerates  into  the 
bronchus 

Entire  right  upper  lobe 
except  at  very  top  converted 
into  nodular  medullary  tu- 
mor extending  to  enlarged 
lymph  nodes  in  anterior  m& 
diastinum.  Compression  of 
upper  cava,  trachea,  and  left 
bronchus 

Bloody  fluid  in  left  pleura. 
Solid  tumor  of  left  lower 
lobe  from  hilus  to  upper  part 
of  lobe.  Tumor  has  invaded 
wall  of  left  main  bronchus 
and  extends  into  its  ramifi- 
cations, completely  obliter 
ating  the  smaller  bronchi 
Lower  part  of  left  lower  lobe 
consists  mainly  of  tumor 
nodules 

Large  tumor  occupying 
greater  portion  of  upper  left 
lobe.  Numerous  nodules  of 
various  sizes  throughout  re- 
mainder of  left  lung  and 
pleura.  Right  lung  normal. 
Effusion  of  yellow  serum  in 
both  pleurae  and  pericardium 

Bloody    serum     in      left 
chest;    clear  serum  in  right. 
Left    pleura   studded    v/ith 
tumor  nodules;  injection 
of  lymphatics  with  tumor. 
Large    masses    of    tumor 
about  the  root  of  lung  pene- 
trating into  the  lung  itself 


Right  lower  lobe  not  ad- 
herent ;  no  bronchial  glands. 
In  the  lower  lobe  surrounded 
by  a  thin  layer  of  lung  tissue 
a  large  tumor,  grayish-white, 
partially  firm  and  hard,  par- 
tially soft;  not  sharply  de- 
fined, but  merging  into  sur- 
rounding lung  tissue.  All 
other  organs  healthy 


None 


No  other 
metastases 


Not  given 


Not  given 


Left  auri 
cle,  pulmon- 
ary veins, 
right  auricle, 
mediastinal 
and  bron- 
chial lymph 
nodes 


No  metas- 
tases 


Bron- 
chial and 
mesenteric 
lymph 
nodes,  both 
suprarenals 


None,  not 
even  a  single 
gland 


Microscopic 
diagnosis 
somewhat 
uncertain. 
Probably  car- 
cinoma  of 
scirrhus-like 
structure 


Alveolar 
structure ; 
isomorphous 
epithelial 
cells 


Scirrhus 


Alveolar 
structure, 
much  necro- 
sis.     Alveoli 
lined  with 
cylindrical, 
sometimes 
cuboidal  epi- 
thelium; also 
large  giant 
cells 


Probably  of  bron- 
chial origin 


Author  suggests 
possibility  of  alveolar 
origin 


Notice  the  very 
slow  and  chronic  pro- 
cess of  the  disease, 
lasting  over  two  years 
with  but  very  slight 
systemic  disturbance 


10 


130 


TABLE    I 


NO. 

AUTHOR 

SEX 

AGE 

LUNG    IN- 
VOLVED 

CLINICAL    SYMPTOMS 

44 

BOUILIAND, 

Journ.       complimen- 
taire  du  Dictionnaire 
des  Sciences  medi- 
cales,  1826,  Vol.  26,  p. 
289 

Observations    sur    le 
Cancer  des  Poumons, 
etc. 

F 

50 

L 

Pain  in  chest,  harassing  cough,  fever. 
Increasing  weakness  and  emaciation. 
Right  lung  normal.  Absence  of 
breathing  over  left  chest.  Duratiott 
of  disease  about  7  months 

45 

BOTJTGTJES, 

Bull,  de  la  Soc.  Ana- 
tom.  de  Paris,   1888, 
657 
Cancer  primitif  du  Pou- 
mon  gauche 

F 

64 

L 

No  previous  serious  illness.  For  3 
months  pain  in  left  chest,  loss  of 
strength  and  appetite  and  much  ema- 
ciation. Occasionally  bloody  stools. 
Some  cough;  no  expectoration;  never 
bloody  sputum.  Tenderness  and  some 
resistance  in  epigastrium.  Flatness 
over  the  whole  of  left  lung.  Almost 
entire  absence  of  vocal  fremitus. 
Heart  displaced.  Hardly  any  dyspnoea. 
Some  few  infraclavicular  glands.  Clin- 
ical diagnosis:  tumor  of  lung  secondary 
to  cancer  of  stomach.  Death  a  few 
days  after  admission  with  intense  pain 
and  dyspnoea 

46 

Boyd, 

Lancet,  1887,  II,  60 
Cancer     of     Bronchial 

Glands  and  Lungs 

M 

38 

R 

No  clinical  history 

47 

Log.  cit. 

F 

50 

L 

No  clinical  history 

48 

Bremker,  Arthur, 
Am.  Jour.  Med.  Sci- 
ences, Vol.  136,  1903, 
No.  6,  pp.  1020-29 

Case  of  Probable  Pri- 
mary Cancer  of  the 
Lung 

F 

50 

L 

Pain  in  left  chest,  cough.  (Shortly 
before  beginning  of  disease  had  been 
assured  that  heart  and  lungs  were 
sound.)  Dulness,  later  flatness  over 
lower  left  lung.  Heart  displaced  to 
right.  Later  dyspnoea,  bulging  of  left 
chest.     Bloody  serum  aspirated 

49 

Bristowe, 

Lancet,  1860, 1.  496 

Not 

mentio 

ned 

Not  mentioned 

CARCINOMA 


131 


SPTTTUM 

AUTOPST   NOTES 

METASTASES 

MICROSCOPE 

BEMABES 

and  large 

polymor- 

phous 

pave- 

ment 

cells; 

once  a 

nest  of 

concen- 

tric epi- 

thelial 

cells  as- 

suring 

the  diag- 

nosis 

Occasion- 

Left  lung  closely  adher- 

Bronchial 

Not  given 

ally 

ent;  pleura  much  thickened 

and  medias- 

bloody, 

and  shrunken;    left  pleural 

tinal  glands 

mucoid, 

cavity  |  smaller  than  right. 

later 

Nearly   whole  of   left   lung 

putrid 

transformed    into    scirrhus- 
like   tumor   with    broken- 
down  areas  in  its  interior. 
Left    main   bronchus   com- 
pletely obliterated  by  tumor 

None 

Left  pleura  thickened  and 
infiltrated  with  tumor,  also 
diaphragm.     Tumor    infil- 
tration throughout  whole  of 
left  lung.     Walls  of  bronchi 
thickened.     Pericardium  in- 
vaded by  tumor.     Heart, 
stomach  and  all  other  organs 
healthy 

Right  lung, 
left  pleura, 
liver,  medi- 
astinal, 
bronchial, 
retroperi- 
toneal 
Ijonph 
nodes,  right 
kidney 

Not  given 

Not  given 

Cancer    of    right    main 
bronchus  reaching  to  bifur- 
cation.    Large  solid  tumor 
in   right   lung   involving 
pleura  and  pericardium 

Bronchial 
lymph  nodes 

Carcinoma 

Not  given 

Cancer  of  root  of  left  lung. 

Upper 

Not  men- 

Obstruction   of    left    main 

left  lobe 

tioned 

bronchus   by  proliferating 

tumor  masses  in  its  lumen 

Not  given 

1500  c.c.  bloody  iSuid  in 

None 

Cyst-adeno- 

Possibly  from  bron- 

left pleura.     Tumor  in  left 

carcinoma 

chus.     (I.  A.) 

lower  lobe 

Not  given 

Specimen  exhibited  to  il- 

Not men- 

Not men- 

This is  undoubted- 

lustrate peculiar  growth  of 

tioned 

tioned 

ly  a  case  of  primary 

132 


TABLE   I 


LUNG    IN- 
VOLVED 


CLINICAL    SYMPTOMS 


60 


61 


BuHD,  E.  Ltcett, 
Transact.  Path.  See 
London,  1891,  p.  55 

Primary  Carcinoma  of 
Lung 


Chiabi,' 

Prag.  Med.  Wochen- 
schr.,  1883,  p.  497 

Zur  Kenntniss  der  Bron- 
chialgeschwulste 


Not 
giv- 
en 


62 


63 


54 


Claisse, 

Bulletin  a  Memoires 
de  la  Soci6t6  Medi- 
cale  des  Hop.  de  Paris, 
1899,  p.  46 

Diagnostic    precoce   du 
Cancer  du  Poumon 
par  I'etude  histolo- 
gique  des  Crachats 

Coats, 

Transact.  London 
Path.  Soc,  Vol.  34, 
1888,  p.  326 

A  Case  of  Multiple  Can- 
cerous Tumors,  many 
of  them  Cystic,  in 
Lungs,  Brain,  Bones, 
etc.  Primary  Tumor 
probably  in  the  Lung 


CoHN,  Pattl^ 
..  Diss.  Leipzig,  1903 
Uber     verhornenden 


55 


R 


70 


M 


M 


M 


50 


17 


60 


Not 
stated 


R 


Admitted  for  right  pleurisy;  dis- 
charged 3  weeks  later  much  relieved. 
Readmitted  16  days  thereafter  with 
stitch  in  side,  cedcema  o2  face,  s,rms  and 
chest;  much  dyspnoea;  dilatation  of 
veins  over  shoulders  and  front  of  chest. 
Slight  dulness  over  limited  area  in 
front  on  right  chest.  No  adventitious 
lung  sounds;  no  heemoptysis.  Death 
about  6  weeks  after  admission 


No  clinical  history  except  "marked 
marasmus  present" 


Health  had  been  perfect  but  began 
to  fail.  Nothing  could  be  found  on 
lungs.  Expectorated  2  particles  about 
the  size  of  a  cherrypit  from  which 
diagnosis  was  made  many  weeks  before 
sjrmptoms  of  tumor   of  lung  appeared 


Entire  clinical  picture  dominated 
by  symptoms  from  nervous  system  — 
vomiting,  headache,  strabismus, 
choked  disc.  Normal  temperature, 
normal  respiration.  Nothing  pointed 
to  disease  of  lungs.  Tumors  appeared 
in  both  femurs,  various  ribs,  and 
around  lumbar  spine.  Convulsions, 
coma,  death.  Duration  of  disease 
about  8  months 


No  clinical  history 


CARCINOMA 


133 


SPUTUM 

AUTOPSY    NOTES 

METASTASES 

MICHOSCOPE 

BEMAHK3 

cancer  in   lung,    radiating 

cancer    of    the    lung 

along  bronchial  tubes 

with   infiltrations 
along    the    bronchial 
ramifications 

Not  men- 

Upper lobe  of  right  lung 

Medias- 

Not men- 

tioned 

infiltrated  with  new  growth. 
Right  bronchus  occluded 

tinal  lymph 
nodes  form- 
ing large 
mass  adher- 
ent to  peri- 
cardium, 
root  of  lung, 
oesophagus, 
and  great 
vessels 

tioned 

• 

No  details 

Primary  tumor  in  left 

Right 

Papillary 

lower  lobe  starting  from 

lung,  both 

structure 

hilus 

pleurae, 
bronchial 
and  supra- 
clavicular 
lymph 
nodes,  liver, 
spleen,  and 
in  cortex 
and  medulla 
of  both  cere- 
bral hemi- 
spheres 

covered  with 
cylindrical 
epithelium. 
No  ciliated 
epithelium. 
Alveolar  epi- 
thelium and 
bronchial 
mucous 
glands  not 
involved 

No  details 

Autopsy  confirmed  clini- 
cal diagnosis 

No  details 

Sections  of 
the  particles 
expectorated 
showed  epi- 
thelioma 

None 

In   upper  part   of  lower 

Bronchial 

Alveolar 

Cystic     adeno-car- 

right  lobe  large  ragged  cav- 

lymph 

and  cystic 

cinoma,  probable  ori- 

ity, the  walls  of  which  are 

nodes. 

structure 

gin     from     bronchial 

formed  of  grayish  neoplasm. 

bones,  lungs, 

with  cylindri- 

mucous glands 

Solid  tumor  adherent  to  bi- 

pancreas. 

cal  epithe- 

furcation  and  bulging  into 

liver,  peri- 

lium_ at  base 

both  main  bronchi;  at  two 

toneum, _ 

and  irregular. 

places  tumors  proliferate 

retroperito- 

cuboid, and 

into  right  main  bronchus 

neal  and 
mesenteric 
lymph 
nodes,  ver- 
tebrae, fe- 
murs, and 
at  least  22 
cystic  tu- 
mors in 
brain 

polymor- 
phous cells  in 
interior  of 
alveoli. 
Much  colloid 
and  mucoid 
material  in 
alveoli  and 
cysts 

No  data 

Cavity  in  left  upper  lobe 

Ribs, 

Typical 

with    necrotic    sequestrum. 

clavicle,  fe- 

cancroid 

Tumor  infiltration  and  nod- 

mur,  spleen, 

with  horny, 

134 


TABLE  I 


65 


56 


57 


68 


59 


60 


61 


62 


Plattenepithelial- 
krebs  der  Lunge 


Davy, 

Lancet,  1882,  II,  257 


Degen, 

..  Dis3.  Ziirich,  1897 

Uber    einen    Fall    von 

primarem       Lungen- 

carcinom 


Delorme, 
,.  Diss.  Jena,  1901 
Uber    primares   Lun- 
gencareinom 


DiNKLEH, 

Verhand.     d.     Path 
Gesell.,  1900,  p.  59 
Ein  Fall  von  primarem 
Lungencarcinom 

Loc.   CIT, 

Discussion  by  Ponick 


Loc.  CIT. 


Loc.    CIT. 

Discussion  by  Langen- 
hans 

DOEMENT, 

Zeitschr.  f .  Heilkunde, 
1902,  III 


M 


M 


M 


M 


M 


43 


50 


LUNG    IN- 
VOLVED 


25 


21 


47 


27 


40 


75 


Both 


Both 


R 


CLINICAL    SYMPTOMS 


Cough;  dulness  and  bronchial  respi- 
ration at  left  apex;  pain  in  left  side, 
impaired  respiratory  motion.  No 
fremitus,  feeble  breathing ;  interspaces 
flattened;  emaciation.  Later  swell- 
ing of  liver  and  ascites 

No  heredity;  always  healthy  until 
half  year  before  admission  when  jaun- 
dice and  pain  in  abdomen.  Physical 
examination  of  lungs  negative.  Large, 
nodulated  liver.  Clinical  diagnosis 
cancer  of  liver,  possibly  cancer  of 
stomach.  At  no  time  any  symptoms 
pointing  to  lungs;   no  cough;   no  pain 

No  heredity;  no  previous  illness. 
Cough,  fever,  scant  expectoration,  re- 
traction of  left  chest  from  1st  to  4th 
ribs;  dilated  veins;  dulness.  Dimin- 
ished respiration  but  normal  vocal 
fremitus.  Large  bronchiectatic  dila- 
tation at  left  base.  Later  clinical 
picture  dominated  by  paralytic  symp- 
toms in  left  arm  and  right  face. 
Severe  headaches  and  neuralgias. 
Later  secondary  nodules  in  numerous 
places  —  lymph  nodes,  ribs,  sternum, 
skull.     Duration  not  quite  one  year 

Diffuse  bronchitis  and  broncho- 
pneumonia 


Healthy  and  strong.  Sudden  death 
from  haemoptysis.  No  other  clinical 
symptoms 

Irritating  laryngeal  cough  for  some 
weeks;  sudden  fever.  Clinical  diag- 
nosis  pneumonia.     Death  in  6  days 


No  clinical  history.    Diagnosis  made 
correctly  during  life 


Cough,  pain  in  side.     Dyspnoea 


CARCINOMA 


135 


AUTOPSY    NOTES 


METASTASES 


MICROSCOPE 


Abundant 
mucous 
expecto- 
ration ; 
no  blood 


None 


Scant, 
occasion- 
ally 
tinged 
with 
blood 


No  details 


None 


Bloody 


No  data 


Purulent 


ules  around  cavity.  Wall 
of  afferent  bronchus  de- 
stroyed by  tumor  but  com 
municates  with  cavity.  Tu 
bercular  cicatrix  in  right 
apex  and  at  Bauhini's  valve 


Clear   serum   in   both 
pleurae.     Left    main    bron 
chus  compressed  by  tumor 
at  the  hilus  penetrating  into 
lung  and  invading  pleura 


Small,  primary  infiltrat- 
ing cancer  of  left  lung  with 
miliary  nodules  along  lym- 
phatics of  left  pleura.  Be- 
sides the  cancer  an  eruption 
of  miliary  tubercles 


Primary  carcinoma  of  left 
bronchus;  right  pulmonary 
vein  perforated  by  tumor 


Both  lungs  uniformly  dis 
eased,    gross   aspect  resem- 
bling most  a  cheesy  pneu- 
monia 


Degenerating  carcinoma 
of  left  main  bronchus  pene- 
trating into  a  large  branch 
of  the  pulmonary  artery 

Hard  carcinoma  of  left 
main  bronchus.  Compres- 
sion of  left  pulmonary  ar- 
tery. Hgemorrhagic  infarc- 
tion of  left  lung 

Extensive  diffuse  infiltra- 
tion of  both  lungs  resem- 
bling pneumonia 

Carcinoma   of    inferior 
right  lobe  extending  into  in- 
ferior cava.     Chronic  tuber- 
culosis of  lung 


liver,  right 
kidney,  left 
adrenal, ret- 
roperitoneal 
glands.  No 
metastases 
in  bronchial 
glands 

Bronchial 
lymph  nodes 


Liver, 
tracheal  and 
bronchial 
lymph  nodes 


Pericardi- 
um, pleura, 
bones  of 
skull,  both 
suprarenals, 
liver,  vari- 
ous long 
bones,  ster- 
num, ribs, 
lymph  nodes 


Stomach 


No  details 


No  details 


Bronchial 
lymph 
nodes 

Diaphragm, 
right  lobe  of 
liver 


pavement 
epithelium 


No  details 


Squamous 
celled  carci- 
noma of 
scirrhous 
type 


Cylindri- 
cal celled  car- 
cinoma 


Tumor    is    simply 
called  cancer 


Carcinoma 


No  details 


No  details 


Cylindri- 
cal celled  car- 
cinoma 

Epithelioma 
said  to  origi- 
nate from 
pulmonary 
alveoli 


136 


TABLE  I 


NO. 

AUTHOH 

SEX 

AGE 

LUNG    IN- 
VOLVED 

clinical  symptoms 

63 

Log.  cit. 

F 

67 

R 

Fever,  dyspnoea,  palpitation,  pain  in 
right  side,  cedcEma  of  both  legs.  Bloody 
effusion  in  right  pleura 

64 

LOC.  CIT. 

M 

47 

R 

No  clinical  history  given 

65 

Log.  err. 

M 

Not 
stated 

R 

Headaches,  pain  in  left  chest,  dysp- 
noea; tenderness  over  right  ribs;  cyano- 
sis, salivation,  clouded  vision;   cough 

66 

Log.  cit. 

F 

63 

R 

No  clinical  history 

67 

Log.  cit. 

F 

79 

Not 
stated 

No  clinical  history 

68 

Log.  cit. 

M 

41 

L 

Severe   headaches,    disturbances    of 
vision    and  hearing;    somnolency    and 
paralysis.     Clinically   diagnosed   as 
tumor  or  tuberculosis  of  brain 

69 

Log.  cit. 

F 

66 

R 

Fever,  cough,  pain  in  right  chest, 
dyspnoea.  Flatness  over  right  pos- 
terior base 

70 

Log.  cit. 

M 

51 

R 

Severe  cough ;  flatness  right  apex 
anteriorly,  bronchial  respiration  and 
rales 

71 

Log.  git. 

M 

29 

L 

Cough,  pain  in  left  chest,  paresis 
left  arm;  fever,  severe  pain  in  back. 
Dulness,  diminished  breathing  in  left 
interscapiilar  space.  Bloody  fluid  in 
pleura 

72 

DOHSCH, 

Diss.  Tiibingen,  1886 
(quoted    by    Passler) 
Ein  Fall  von  primarem 
Lungenkrebs 

F 

54 

R 

No  clinical  history 

CARCINOMA 


137 


Mucoid 
and 

haemop- 
tysis 

Not  stated 


Scant 


No  details 


No  details 


Not  stated 


Abundant 


Haemop- 
tysis 


Bloody 


No  details 


AUTOPSY    NOTES 


Carcinoma  of  middle  and 
lower  right  lobes;  carcinosis 
of  right  lung 


Carcinoma  of  bronchi  and 
right  lung;  also  tuberculosis 


METASTASES 


Medias- 
tinal lymph 
nodes,  liver, 
and  thyroid 

Liver,  bron- 
chial lymph 
nodes 


Bronchial  cancer  of  right 
upper  lobe ;  stenosis  of  bron^ 
chus.     Old  apex  tubercu- 
losis 


Carcinoma  of  right  bron- 
chus 


Carcinoma  of  left  inferior 
lobe 


Two  medullary  tumors  in 
right  upper  lobe,  starting 
from  right  main  bronchus  at 
root  of  lung  and  extending 
into    bronchus    and    upper 


Bronchial 
lymph  nodes 
left  kidney 


Not  stated 


Tumor  in  main  bronchus 
of  right  lower  lobe  ulcerat- 
ing into  lumen  and  almost 
completely  obstructing  it. 
From  bronchus  tvunor  pene^ 
trates  into  right  lung 

Carcinoma  of  right  in- 
ferior lobe;  tuberculosis  of 
right  lung 

Carcinoma     proliferating     Bronchial 
along  bronchi  of  lower  lobe  lymph  nodes 

In  left  lower  lobe,  sur-         7  metas- 
rounding     main     bronchus,  tases  in 
cancerous  mass  radiating  in-  brain ;  no 
to  surrounding  lung  tissue     others 


MICKOSCOPE 


No  details 


B.ronchial  ele- 
ments found 
normal  and 
origin  of 
tumor  re- 
ferred to 
alveolar  epi- 
thelium 

Carcinoma 
originating 
from  bron- 
chial epithe- 
lium 


Not  stated 


No  details 


Bronchial 
and  medias- 
tinal lymph 
nodes,  peri- 
cardium, 
both  pleurae 


Bronchial 
lymph  nodes 
perforating 
into  auricle 

Cranium, 
6th  rib, 
Uver,    bron- 
chial and 
retroperito- 
neal lymph 
nodes,  brain, 
right  kidney 


Bronchial 
lymph 
nodes, 
lungs,   liver, 
spleen,  kid- 


Cylindrical 
cells  of  ade- 
nomatous 
structure 
originating 
from  bron- 
chial mucous 
glands 

Cylindrical 
celled  adeno- 
matous can- 
cer, originat- 
ing probably 
from  bron- 
chial mucous 
glands 

No  details 


No  details 


Large  poly- 
morphous 
epithelial  cells 
tending  to 
fatty  degen- 


138 


TABLE    I 


73 


74 


76 


76 


77 


Dbtsdalb, 

Medical  Press  &  Cir- 
cular, Vol.  LIII,  N.S., 
London,  1892,  p.  628 

Case  of  Cancer  of  Left 
Liing 


Ebert 

Virch.  Arch.,  Vol.  49, 

1870,  p.  61 
Zur  Entwickelung  des 

Epithelioma    der  Pia 

und  der  Lungen 


Ebstein, 

Deut.  Med.  Wochen- 

schr.,  1890,  p.  921 
Zur  Lehre  vom   Krebs 

der  Bronchien  und 

der  Lunge 


Log.  cit. 


Ehrich, 

..  Diss.  Marburg,  1891 

Uber        das       primare 

Bronchial-  und  Lun- 

gencarcinom 


M 


M 


M 


LUNG    IN- 
VOLVED 


51 


47 


67 


64 


52 


R 


CLINICAL    SYMPTOMS 


Sick  for  3  months  with  bronchitis; 
coughed  up  much  pus.  Dulness  over 
left  base,  diminished  fremitus  and 
moist  rales.  Dulness  gradually  ex- 
tends; emaciation.  At  one  time 
cough  less  troublesome  and  felt  better. 
More  breathing  heard  over  left  lung. 
Later  increasing  diilness,  symptoms  of 
cavity,  diarrhoea  and  death.  During 
life  diagnosis  was  doubtful  and  malig- 
nancy suspected  only  towards  end. 
Duration  about  10  months 


Clinical  history  refers  mainly  to 
brain  symptoms.  Repeated  examina- 
tions of  chest  negative.  A  few  days 
before  death,  fever  and  cough.  Dysp- 
noea and  some  cyanosis.  Examination 
showed  extensive  dulness  over  left 
lower  lobe  and  bronchial  breathing; 
some  friction 

Family  history  of  cancer.  Clinical 
nosis  myocarditis,  dilatation  of 
heart,  emphysema,  bronchitis,  effu- 
sion in  right  pleural  cavity,  diabetes. 
Disease  extended  over  a  number  of 
years  with  occasional  improvement. 
For  several  years  no  signs  on  lungs 
except  some  rales.  Sudden  death 
from  heart  failure 

Pain  in  left  chest  extending  later  to 
back  and  right  chest.  No  cough,  in- 
creasing emaciation,  slight  tempera- 
ture; dyspnoea;  dulness  at  left  base 
which  remains  stationary.  Ribs  un- 
even and  tender;  slight  area  of  dulness 
on  right  side.  Exploratory  puncture 
negative.  Tenderness  of  liver  with 
enlargement  of  left  lobe.  Two  days 
before  death  tumor  appeared  on  6th 
rib  right  side.  3  days  before  death 
stupor  and  paresis  of  left  upper  eyelid. 
Hemoglobin  62;  reds  3,492,000;  whites 
32,000 

For  some  months  pain  in  both  sides 
of  chest  and  between  scapulae,  later 
paralysis  of  both  legs.  Very  slight 
cough.  Clinical  picture  dominated  by 
typical  symptoms  of  transverse  mye- 
litis. Nothing  characteristic  in  lungs. 
Fever  up  to  104 


CARCINOMA 


139 


SPUTUM 

AUTOPSY   NOTES 

METASTASES 

MICHOSCOPE 

REMARKS 

cava.     Compression  of  pul- 

ney,  frontal 

eration 

monary  arteries 

bone,  and 
dura  mater 

Mostly  pro- 

Pleura   firmly    adherent. 

Not  men- 

Not men- 

Probably bronchial 

fuse,  at 

Left  lung  contains  numerous 

tioned 

tioned 

carcinoma  from  hilus 

times   of- 

abscesses.    Large  cavity  at 

fensive, 

apex  containing  pus;   larger 

some- 

cavity   at    base    containing 

times 

blood,  pus  and  debris.    Rest 

much 

of  lung  infiltrated  with  can- 

pus; occa- 

cerous     growth      radiating 

sionally 

from  posterior  mediastinum 

bloody. 

Several 

hsemop- 

tyses.  No 

tubercle 

bacilli 

None 

Left  lung  completely  infil- 
trated with  whitish  medul- 
lary mass;   small  nodules  of 
similar    character    in    right 
lung 

None 

Alveolar 
structure 
lined  with 
ciliated  epi- 
thelium 

None 

Main  tumor  in  peribron- 

Peritracheal 

Cylindrical 

chial  tissue  of  right  lower 

and  retro- 

celled carci- 

lobe;   strands  of  tumor  in 

peritoneal 

noma 

both  lungs  along  peribron- 

lymph nodes 

chial  and  perivesicular  lym- 

phatics 

None 

Carcinoma  from  left  main 

Regionary 

Cylindrical 

bronchus  at  root,  proliferat- 

lymph 

celled  carci- 

ing into  left  lower  lobe 

nodes, 
pleura,  liver, 
gall-bladder, 
kidneys, 
both  supra- 
renals, 
brain,  pan- 
creas, peri- 
toneum, and 
various 
bones 

noma 

Scant,  mu- 

Carcinoma   in    bronchus 

Bronchial, 

_No  details; 

copuru- 

and tissue  of  left  upper  lobe. 

cervical  and 

origin  from 

lent,  no 

Continuous  propagation  to 

retroperito- 

bronchial mu- 

tubercle 

pleura  and  6th  to  8th  dorsal 

neal  lymph 

cous  glands 

bacilli,  no 

vertebrse  with   compression 

nodes,  liver. 

elastic 

myelitis.     Diffuse     carcino- 

spleen, kid- 

fibres 

sis  of  pleura  and  lung 

neys,  right 
suprarenal, 
thyroid,  hy- 

140 


TABLE    I 


NO. 

AUTHOR 

SEX 

AGE 

LUNG    IN- 
VOLVED 

CLINICAL    SYMPTOMS 

78 

Log.  git. 

M 

51 

R 

No  heredity.  Always  well  until 
short  time  before  admission  when 
some  bronchitis  and  later  haemoptysis. 
No  dyspnoea;  not  much  pain.  Dul- 
ness,  diminished  respiration  and  voice 
over  right  upper  lobe  which  dis- 
appeared later.  Marked  emaciation. 
Bloody  effusion  in  right  chest;  large 
lymph  node  in  right  a,xilla 

79 

Log.  cit. 

F 

56 

R 

Clinical  diagnosis;  tumor  of  anterior 
mediastinum 

80 

Elisbebg, 

Diss.    KSnigsberg, 

Uber   disseminirte^ 
Miliarkarzinose; 
besonders  der  Lungen 
ohne  makroscopisch 
erkennbaren      prima- 
ren  Tumor 

M 

27 

R 

No  heredity.  Spasmodic  dry  cough 
worse  on  lying  down;  increasing 
dyspnoea  and  weakness;  some  cyanosis; 
no  emaciation;  no  fever.  Right  chest 
somewhat  sunken,  drags  in  respira- 
tion. Dulness  over  right  chest  with 
loss  of  breathing  and  voice.  Left 
chest  normal.  Blood  and  urine  nor- 
mal. Duration  of  disease  4  to  6 
months 

81 

Ennet, 

Diss.  Greifswald, 

1902  (after  Angel- 

hoff) 
Ein  Fall  von  primarem 

Krebs     der     rechten 

und  Tuberkulose  der 

linken  Lunge 

M 

62 

R 

Cough  and  dyspnoea  dating  from 
fall;  later  flatness  over  right  chest, 
dulness  above.  On  aspiration  turbid 
bloody  fluid  containing  clumps  of  large 
epithelial  cells.  Increasing  dyspnoea. 
Duration  about  year  and  a  half.  Clin- 
ical diagnosis:  pulmonary  tuberculosis 

82 

Ernst, 

Ziegiers  Beitrage, 
Vol.  XX,  1896,  p.  155 

M 

50 

R 

Abrupt  onset  of  disease  with  obscure 
clinical  symptoms  suggesting  menin- 
gitis or  cerebral  haemorrhage ;  at  same 
time  cough,  dulness  at  right  apex. 
Patient  died  shortly  after  he  began  to 
complain 

CARCINOMA 


141 


SPTTTUM 

AUTOPSY   NOTES 

METASTASES 

MICROSCOPE 

EEMARKS 

pophysis, 

dura  and 

1st  and  7th 

left  ribs 

Mostly 

Carcinoma   from   right 

Pericar- 

Alveolar 

Supposed  origin 

bloody ; 

main     bronchus     involving 

dium,  chest 

structure 

from    bronchial    mu- 

at one 

pleura  and  chest  wall.   Ribs 

wall,  ribs, 

with  large 

cous  glands 

time  ex- 

perforated by  cancer.       In 

pleura. 

polymor- 

pectora- 

lower lobe  of   right  lung  a 

bronchial 

phous  cells 

tion  of 

large  cavity  filled  with  nec- 

nodes and 

villous 

rotic  tissue   and   communi- 

diaphragm 

and 

cating  with  right  bronchus, 

bloody 

which  is  nearly  completely 

masses 

obstructed  by  large  prolifer- 

which 

ating  tumor 

con- 

tained 

cancerous 

material 

No  details 

Tumor  lower  part  of  tra- 

Bronchial 

Same  as 

chea  and  right  main  bron- 

and medias- 

above 

chus  and  its  branches.    Com- 

tinal lymph 

plete   atelectasis   of    right 

nodes,  left 

tung.     Hard,  firm,  white 

lung,  liver, 

tumor  at  the  root  matting 

heart 

together   pleura,   trachea,  _ 

bronchus,  large  vessels,  peri- 

cardium, compressing  upper 

part  pulmonary  artery.  Tu- 

mor infiltration  left  lung 

Scant,  mu- 

Effusion   in   right   chest. 

Bronchial 

Transition 

coid,  oc- 

Miliary carcinomatous  nod- 

lymph 

from  cylindri- 

casionally 

ules   over   both   lungs    and 

nodes,  peri- 

cal and  cu- 

bloody 

pleurae.      Compression    of 

toneum  and 

boid  to  small 

right    bronchus;     extensive 

mucous 

polyhedral 

carcinomatous    infiltration 

membrane 

cells 

through  the  lymph  channels. 

of  bladder 

Papillary    and    nodular  tu- 

mor masses  in  bronchial  mu- 

cous membrane 

Often 

_  Carcinoma   of    whole    of 

No  details 

Typical  cy- 

bloody. 

right  lung  and  right  pleura; 

lindrical  epi- 

contains 

ulcerating    tuberculosis     of 

thelial  cells 

tubercle 

left  upper  lobe 

bacilli 

Mucopuru- 

Carcinoma of  bronchus  of 

Lsmiph 

Capillary 

lent 

right  upper  lobe  extending 

nodes,  dura. 

structure  _ 

to  main  bronchus 

brain,  cere- 
bellum, left 
suprarenal 

covered  with 
epithelium 
resembling 
epidermis 
with  prickle 
cells  and  ker- 
ato-hyaline; 
also  spindle 
shaped  giant 

1 

cells 

142 


TABLE   I 


83 


84 


85 


FiNLET  &  PaBKEH, 

Medical  Chirur. 
Trans.,  London, 
1877,  Vol.  LX,  313- 
324 
Primary       Cylindrical- 
celled  Epithelioma  of 
Lung 

FOA, 

Giorn.  della  R.  Acad. 
di  Med.  di  Torino, 
Vol.42,  1894,  p.  Ill 
Un  Caso  Cancro  primi- 
tive del  Pulmone 


Frankel,  a. 

Spezielle  Pathologie 
u.  Therapie  der  Lun- 
genkrankheiten,  1904 


86  Loc.  ciT. 


87 


Fbiedlander, 

Fortschr.  d.  Med., 

1885, 1,  p.  307  (after 

Passler) 
Cancroid  in  einer  Lun- 

gencaverne 

Froelich, 
..  Diss.  Berlin,  1899 
Uber  das  primare 
Lungencarcinom 


M 


M 


37 


Not  St 


40 


M 


M 


M 


52 


Not 
stated 


42 


LUNG    IN- 
VOLVED 


ated 


CLLNICAL    SYMPTOMS 


Pain  in  left  chest,  cyanosis,  dyspncea, 
clubbed  fingers,  cough,  diminished 
respiratory  movement  of  left  chest. 
Flatness,  feeble  breathing,  diminished 
fremitus.  Aspiration  negative.  Later 
enlargement  of  5upracla\'icular  glands 


No  cUnical  history 


In  perfect  health  until  taken  with 
chill  and  fever  up  to  104;  dyspnoea 
flatness  over  whole  of  right  lower  lobe, 
loss  of  fremitus,  diminished  respira- 
tion. Pneumonia  with  gangrene  of 
lung  was  diagnosed.  Death  before 
2nd  week  of  disease  • 


For  2  years  pain,  cough,  dulness 
over  left  lower  lobe,  feeble  bronchial 
respiration,  abundant  rales.  Dulness 
gradually  extends  over  greater  part 
of  left  chest.  Puncture  negative. 
Roentgen  raj^  showed  complete  in- 
duration of  entire  left  lung.  Later 
flatness  gradually  diminishes  until 
percussion  note  becomes  normal  every- 
where except  one  small  area.  Later 
again  becomes  tympanitic  and  finally 
absolutely  flat  until  death.  Inguinal 
IjTuph  node  had  been  removed  and 
found  carcinomatous,  which  corrobo- 
rated clinical  diagnosis  of  carcinoma  of 
left  lung.     Duration  about  2|  years 


No  clinical  history 


No  heredity.  Cough,  pain  in  left 
chest,  debility,  anorexia;  irregular  flat- 
ness over  left  chest;  diminished  voice 
and  respiration.  Hsemorrhagic_  effu- 
sion in  left  pleura;  later  retraction  of 
left  chest,  cyanosis,  intense  dyspnoea; 
later  still  amphoric  breathing  in  lefti 


CARCINOMA 


143 


SPUTUM 

AUTOPSY    NOTES                  METASTASES 

MICROSCOPE 

EEMAEK8 

Pink 

Large,  soft,  pulpy  tumor  Mediastinal 

Alveolar 

in  upper  left  lung                     and  supra- 

arrangernent 

clavicular 

with  typical 

lymph 

cylindrical 

nodes, 

cells 

pleura,  both 

lungs,  liver, 

right  kidney 

No  details 

Author    calls    tumor    a 

Liver, 

Partly  cy- 

broncho-pulmonary cancer 

kidneys 

lindrical, 
partly  polyg- 
onal pave- 
ment epi- 
thelium. 
Author  at- 
tributes ori- 
gin cylindri- 
cal epithe- 
lium to 
bronchi; 
pavement  to 
alveoli 

Mucopu- 

Right lower  lobe  bronchi- 

LjTnph 

Cylindrical 

rulent, 

ectatic    ca\dties    filled   with 

nodes  at 

celled  carci- 

copious; 

puriform  secretion.     Prolif- 

hilus 

noma 

later 

eration  into  main  bronchus 

dirty 

of  lower  lobe  of  medullary 

brown 

tumor  almost  completely 

and  foetid 

obstructing  lumen  and  per- 
forating through  wall 

Occasion- 

Occlusion of   left   main 

Inguinal 

Cylindrical 

ally 

bronchus  with  nodular  med- 

lymph 

celled  carci- 

bloody 

ullary  tumor  size  of  a  man's 
fist  at  hilus,  extending  into 
lung  tissue 

nodes;  gen- 
eral carcino- 
sis of  entire 
left  lung 

noma 

No  details 

A  white  medullary  mass 
from  bronchus  of  left  upper 
lobe.     Only  in  this  bronchus 
and  in  a  tubercular  ca\'ity 
in  left  lung  has  cancer  de- 
veloped 

None 

Horny  pave- 
ment epithe- 
lium with 
typical  can- 
croid pearls 

Scant,  occa- 

Abundant bloody  exudate 

Both  lungs, 

Pavement 

sionally- 

in  left  chest.     Pleura  much 

pleura,  peri- 

epithelium 

bloody; 

thickened  and  adherent  on 

cardium. 

later 

all  sides  to  extensive  tumor 

bronchial. 

raspberry 

masses,  so  that  exudate  is 

mediastinal. 

jelly  and 

completely   encapsulated. 

cervical 

contains 

Posterior  portion   of  upper 

lymph 

144 


TABLE   I 


NO. 

AUTHOR 

SEX 

AGE 

LUNG    IN- 
VOLVED 

CLINICAL    SYMPTOMS 

chest.  Enlargement  of  cer%'ical  lymph 
nodes;  nodular  enlargement  of  liver; 
paralysis  of  left  recurrent;  death. 
Duration  of  illness  about  9  months 

89 

Log.  err. 

M 

77 

L 

No  heredity.  Pain  in  left  side, 
cough.  Increasing  dulness  left  chest, 
bronchial  breathing  and  rales.  Re- 
traction of  left  chest  with  cessation  of 
respiratory  movements.  Increasing 
cachexia.  Clinical  diagnosis  pneumo- 
nia and  marasmus 

90 

FrrcHS, 

Diss.  Miinchen 
Beitrage  zurKennt- 
niss    der     primaren 
Geschwiilstbildungen 
in  der  Lunge 

F 

32 

Both 

No  clinical  history 

91 

Log.  git. 

F 

56 

R 

No  clinical  data  except  that  the 
diagnosis  was  cerebral  atrophy 

92 

Log.  err. 

M 

59 

Both 

No  clinical  history  except  marked 
emaciation 

93 

Log.  cit. 

M 

64 

Both 

No  clinical  history  except  during 
stay  in  hospital  intestinal  obstruction 
was  suspected.     Great  emaciation 

94 

FUCHS, 

Diss.  Leipzig,  1890 
Beitrage   zur   Casuistik 
des    primaren    Lun- 
gencarcinoms  (after 
Passler) 

M 

73 

R 

No  cUnical  history 

95 

Log.  cit. 

M 

51 

R 

No  clinical  history 

96 

Geipel, 

Centralbl.  f.  Allgem. 
Pathol,  u.  path.  Anat. 
X,  1899,  p.  848 

M 

70 

L 

Patient  suffered  for  some  time  from 
severe  pulmonary  trouble.  No  other 
clinical  history  given 

CARCINOMA 


145 


AtTTOPST    NOTES 


At  first 
none, 
later 
scant,  no 
tubercle 
bacilli 


and  lower  lobes  contains 
masses  of  tumor  in  which 
are  found  numerous  cavities 
filled  with  pus 


Encapsulated  bloody  exu 

date  in  left  pleura.  Upper 
left  lobe  a  shell  of  lung  tissue 
infiltrated  with  tumor  and 
surrounding  cavities  filled 
with  putrid  and  degenerat- 
ing tumor  material 

Primary  cylindrical  celled 
carcinoma  of  both  lungs  ap 
pearing  in  numerous  nod 
ules,  many  of  them  conflu- 
ent. Fibrinous  effusion  in 
right  chest 

Medullary  infiltration  of 
right  lung  with  cavity  in  up- 
per lobe.  Foci  of  red  and 
yellow  softening  in  cortex  of 
left  anterior  lobe  of  brain 

Primary  cancer  with  nod- 
ules in  both  lungs  in  great 
numbers     of      all     si^es. 
Chronic   interstitial  pneu- 
monia 

Medullary  nodules  in  left 
upper  lobe.  Bronchial  mu- 
cous membrane  bulged  by 
nodules.  Large  cavity  in 
right  middle  lobe  filled  with 
pedunculated  soft,  reddish- 
brown  material.  Hsemor- 
rhagic  effusion  in  pericar- 
dium with  retraction  of  left 
lung 

Carcinomatous  tumor  size 
of  an  apple  in  right  lower 
lobe;   softening  in   interior 


METASTASES      MICROSCOPE 


Subpleural  tumor  size  of 
an  apple  in  right  upper  lobe. 
Necrotic  cavity  in  interior. 
Origin  from  bronchial  wall 

Carcinoma  of  left  main 
bronchus  penetrating  into 
left  auricle  and  also  into 
aorta,  but  not  to  the  intima 


nodes,  oeso- 
phagus, 
liver,  endo- 
cardium of 
right  ventri- 
cle, bladder 

Bronchial 
lymph  nodes 


No  details 


Numerous 
in  dura 


None 


Pericardium 
and  liver 


None 


Right  lower 
lobe,  region- 
ary  lymph 
nodes,  liver 

Not  men- 
tioned 


Squamous 
epithelium 


Ciliated 
cylindrical 
celled  epithe- 
lium 


No  details 


No  details 


No  details 


Pavement 
epithelium 


Cylindrical 
celled  carci- 


Alveolar 
structure,  cy- 
lindrical cells, 
here  and 
there  ap- 
proaching 
pavement 
epithelium 


11 


146 


TABLE   I 


LUNG    IN- 
VOLVED 


CLINICAL    SYMPTOMS 


97 


99 


100 


GOLDSCHMIDT, 

Corresp.-blatt  f. 
Schweizer  Aerzte, 
1886,  XVI,  p.  67-69 
Medullar  Carcinom  der 
linken  Lunge 

GOUGEROT, 

Bull,  de  la  Sec.  Ana- 
torn,  de  Paris,   1905, 
p.  294 
Cancer  primitif  du  Pou- 
mon  (Epithelioma 
pavimenteux  bron- 
cho-pulmonaire)  a 
Globes  epidermiques 

Geun-wald, 

Milnch.  med.  Wo- 

chenschrift,  1889,  No. 

32-33 
Fall  von  primarem 

Pflasterepithelkrebs 

der  Lunge 


Hall  &  Tribe, 
Lancet,  1905, 1 

Carcinoma  of  Bronchus 
and  Liver  in  a  Youth 
of  17  with  Glycosuria 


M 


M 


47 


46 


R 


M 


32 


M 


17 


101 


BLi.MPELN, 

St.  Petersburg  Med, 
Wochenschrift,   1887, 
No.  17 
Fall      von     primarem 
Lungen-Pleura     Car- 


M 


62 


Progressive  emaciation,  dyspnoea, 
pain,  dilated  superficial  veins.  Flat- 
ness, absence  of  voice  and  breathing 
over  greater  part  of  left  chest.  No 
fever;  no  cough.  700  c.c.  clear  bloody 
serum  aspirated  from  left  chest 

No  heredity.  Pulmonary  tubercu- 
losis of  old  standing.  After  grippe, 
dyspnoea  with  cough  and  f ever._  Later 
polyuria  and  polydipsia.  Rapid  ema- 
ciation; some  pain.  Urine  free  from 
albumin  or  sugar,  though  over  8000  c.c. 
voided  daily.  Later  painful  points  on 
vertebrae;  pains  along  right  arm. 
Clinical  diagnosis  tuberculosis 

Pain  in  chest.  Abnormal  sensations 
in  throat.  Dyspnoea,  paralysis  of  left 
recurrent  laryngeal.  At  that  time 
heart  and  lungs  found  normal.  Later 
dulness  over  left  upper  chest;  absence 
of  breathing.  Physical  signs  vary. 
Clinical  diagnosis  tumor  of  posterior 
mediastinum  compressing  heart  and 
lungs  and  left  recurrent  nerve.  Aspira- 
tion practically  negative.  Some  cough. 
Duration  about  one  year 

For  3  months  cough,  dyspnoea,  ema- 
ciation; thereafter  intense  itching, 
enormous  appetite,  polyuria;  some 
cyanosis;  oedoema  of  face,  neck,  and 
feet;  purpuric  spots  partly  suppurat- 
ing over  the  legs.  Swellings  filled  with 
fluid  over  scapula,  back,  anus,  and  left 
arm.  Bronchial  breathing  with  some 
rales  over  left  apex.  Enlarged  nodular 
liver;  some  fever.  Urine  contains 
much  sugar;  some  diacetic  acid.  Sud- 
den collapse  and  death.  Duration 
about  3  months.  Clinical  diagnosis 
pyaemia  with  suspicion  of  tuberculosis 

No  heredity;  disease  started  with 
slight  fever  and  enlarged  spleen; 
treated  as  malaria  and  improved. 
Later  pain  in  left  chest  and  dyspnoea; 
pleuritic  effusion  which  was  absorbed 
without  tapping.  Later  slight  cough 
followed  by  emaciation  and  general 
cachexia  without  subjective  symp- 
toms. No  pain,  good  breathing,  good 
appetite.  Physical  signs  suggested 
merely  incomplete  absorption  of  pleu- 
ritic effusion.  Duration  of  disease 
probably  not  more  than  one  year 


CARCINOMA 


147 


AUTOPSY    NOTES 


METASTASES 


MICEOSCOPE 


None 


Mucopuru- 
lent, often 
bloody, 
contains 
tubercle 
bacilli 


Scant,  occa- 
sionally 
bloody 


Mucopu- 
rulent, 
bloody, 
no  tuber- 
cle bacilli 


Scant,  gela- 
tinous, 
occasion- 
ally 
bloody 
or  pink. 
Micro- 
scopic ex- 
amina- 
tion 
showed 
numer- 
ous epi- 
thelial 
cells  sug- 
gesting 
tumor, 
from 
which 
alone  the 


Entire  left  lung  except  up- 
per portion  of  upper  lobe 
converted  into  medullary 
cancer 


Neoplasm,  involving  en- 
tire right  upper  lobe  with 
cavity.  Right  main  bron- 
chus at  root  obstructed  by 
tumor  up  to  bifurcation. 
Compression  of  tracheal  and 
cervical  plexus 


Solid  tumor  size  of  fist  in 
central    portion    left  lower 
lobe.      No    cavities.      All 
bronchi  compressed;  cesoph 
agus  matted  to  trachea  by 
tumor 


Irregular  tumor,  lower 
lobe  of  left  lung,  starting 
from  hilus,  spreading  along 
bronchus  into  lung;  main 
bronchus  almost  occluded. 
Pancreas  normal 


None  Not  men- 

tioned 


In  lower  lobe  a  tumor  the 
size  of  a  fist,  broken  down  in 
centre,  but  surrounded  by 
normal  lung  tissue 


Peritra- 
cheal, peri- 
bronchial 
lymph 
nodes;  left 
kidney 


Bronchial 
and  medias- 
tinal lymph 
nodes;  left 
ventricle 
and  2  nod- 
ules in  liver 


Upper  lobe, 
liver,  retro- 
peritoneal 
and  cervical 
lymph 
nodes,  parts 
of  skull 


None 


Typical  pave- 
ment epithe- 
lium with 
horny  pearls. 
Origin  from 
bronchus 


Pavement 
epithelium 


Columnar 
celled  carci- 
noma.    Ori- 
gin from 
bronchus 


148 


TABLE   I 


102 


103 


104 


105 


106 


Handpord, 

London  Path.  Trans. 
Vol.  39,  p.  48 

Two  Cases  of  Medias- 
tinal Cancer 


Log.  cit. 


Handford, 

London  Path.  Trans., 

Vol.  40,  p.  40 
Primary   Carcinoma  of 

Left  Bronchus 


Handford, 

London  Path.  Trans., 

Vol.  41,  p.  37 
Carcinoma  of  Root  of 

Lung  (after  Passler) 


Harbitz,  Francis, 
Norsk  Mag.  f.  Lae- 
gevidenskaben.,  Aug., 
1903,  p.  715 

Primarer  Krebs  in  einer 
Lunge  mit  bronchiec- 
tatischen    Cavemen ; 
Metastasen  im  Ge- 
hirn  und  in  dem 


M 


M 


M 


M 


45 


40 


64 


63 


49 


LUNG    IN- 
VOLVED 


R 


CLINICAL    SYMPTOMS 


Cough  and  failing  health  6  months 
before  admission.  Loss  of  flesh,  pain 
between  shoulders  and  at  sternum. 
Difficulty  in  swallowing  anything  but 
fluids.  On  admission:  difficulty  in 
swallowing  most  urgent  symptom  and 
steadily  increasing.  Profuse  haemop- 
tysis and  death.  Duration  of  disease 
about  7  months 

Cough  more  or  less  for  20  years. 
5  years  ago  profuse  haemorrhage.  2 
years  ago  loss  of  voice  for  2  months; 
unable  to  work  for  18  months;  much 
loss  of  flesh;  musctilar  pains.  Hectic 
temperature,  occasionally  up  to  104f . 
Dulness  over  nearly  all  of  right  lung, 
especially  over  lower  lobe.  Later 
pleuritic  effusion  in  right  chest;  aspira- 
tion 30  ounces  of  turbid  serum.  Later 
swellings  in  upper  humerus,  right 
deltoid,  left  upper  arm  and  left  thigh. 
Smaller  nodules  in  scalp.  Sudden 
death  from  haemoptysis 

Well  until  5  years  before  admission; 
then  had  fall  and  hurt  chest.  Cough 
and  loss  of  flesh  since.  Deficient  ex- 
pansion of  left  chest;  dull  percussion 
especially  in  upper  part.  Feeble,  dis- 
tant tubular  breathing,  finally  com- 
plete absence  of  breathing  sounds. 
Paroxysms  of  dyspnoea;  hoarseness. 
Clinical  diagnosis:  new  growth  or 
aneurysm  pressing  on  left  main  bron- 
chus. Death  from  profuse  haemop- 
tysis. Duration  of  disease  about  6 
months 

None  given 


Tubercular  family  history.  Had 
syphilis.  At  34  years  had  influenza 
and  coughed  ever  since.  Sudden  acute 
pains  in  both  sides  of  chest ;  bedridden 
since.  Sweating;  intense  thirst.  On 
admission  dulness  over  left  lung;  rales 
over  both  lungs.  To  the  left  of  ver- 
tebral column  on  level  with  10th  rib  a 
long,  pseudo-fluctuating  mass.     Fusi- 


CARCINOMA 


149 


AUTOPSY  NOTES 


METASTASES 


MICROSCOPE 


Large  tumor  in  left  lower 
lobe  covered  by  thickened, 
infiltrated  pleura.  Tumor 
proliferates  into  mediasti- 
num, where  there  is  large 
cavity  filled  with  bloody 
fluid  communicating  with 
main  bronchus  and  left 
auricle 

Carcinoma  of  root  of  right 
lung  spreading  along  bron- 
chial ramifications  and  large 
vessels.  In  lung  tumor 
masses  in  parts  softened 
and  forming  cancerous  cav- 
ities from  which  haemorrhage 
originated 


Hypostatic  pneumonia 
right  lung.  New  growth  had 
spread  along  interior  of  left 
bronchus,  completely  filling 
its  lumen,  and  reaching  up 
into  trachea  above  bifurca- 
tion. Numerous  small  tU' 
mor  nodules  over  left  vis 
ceral  pleura 


Carcinoma  of  root  of  left 
lung,  obliterating  lower  sec- 
ondary bronchus,  and  pro- 
liferating  along    bronchial 
ramifications 


Mucopu-  Small  tumor  in  rectus  ab- 

rulent,  dominis,  also  in  musculature 
several  of  back  near  spinal  column, 
times  Upper  surface  of  right  lung 
pure  studded  with  nodules  often 

blood,  no  umbilicated.       On    section 
tubercle    lung   shows    many   grayish 
bacilli        red  tumor  nodules,  both  dis 
Crete  and  confluent.     Much 


Medias- 
tinum, cer- 
vical lymph 
nodes,  liver, 
left  auricle, 
pericardium 


Bronchial 
lymph 
nodes,  vari- 
ous muscles 
of  trunk, 
various 
bones,  skin, 
kidneys 


Bronchial 
and  medias- 
tinal lymph 
nodes,  liver 


Left  pleura, 
liver 


Right  lung 
brain,  cere- 
bellum, ribs 
sternum, 
liver,  kid- 
neys, mus- 
cles of  back 
and  abdo- 


Typical  al- 
veolar struc- 
ture of  scir- 
rhous carci- 
noma 


Alveolar 
structure, 
abundant 
stroma,  epi- 
thelial cells 


Carcinoma 
of  scirrhous 
type,  origi- 
nating from 
mucous  mem- 
brane of  bron 
chua 


Alveolar 
structure, 
well  devel- 
oped stroma 
and  abundant 
epithelial 
cells 

Alveolar 
structure ; 
alveoli  lined 
with  high  cy- 
lindrical cells. 
Small  bron- 
chi contain 
these  cells  in 
active  prolif- 


150 


TABLE    I 


107 


108 


109 


110 


111 


112 


113 


Knochensystem 


Loc.  CIT. 
p.  729 


Loc.  CIT. 

(postscript) 


Haebitz, 

Quoted  from  Zeit- 
schr.  f.  Krebsforsch. 
I,  1904,  p.  154 


Hahkis, 

St.  Bartholomew's 
Hosp.    Reports,    Vol. 
28,  1892,  p.  73 

Intrathoracic  Growths 

Haktmann, 
..  Diss.  Kiel,  1896 
tJber  Lungenkrebs  vom 
Bronchus  ausgehend 


Hauff, 

Schmidt's  Jahr- 
biicher.   Vol.    182, 
88 

Ein  Fall  von  Mark- 
schwamm  der  Lunge 
und  des  Herzens 


Hatjte-Cceur, 

Progres  Med.,  1886, 
2nd  series.  III,  460- 
462 


M 


M 


M 


M 


49 


69 


40 


54 


69 


52 


64 


LUNG    IN- 
VOLVED 


R 


Both 


R 


Both 


CLINICAL    SYMPTOMS 


form  enlargement  of  9th  rib  in  left 
axilla.  Puncture  of  tumor  at  10th 
rib  reveals  brown  colloid  material 
containing  round  or  oval  cells  with 
fatty  degeneration.  No  fever  while 
in  hospital.  Died  from  marasmus  9 
days  after  admission 

Sick  for  a  long  time.  Symptoms  of 
chronic  cedoema  of  lung  with  short  per- 
cussion note.  Ronchi  over  both  lungs. 
Slight  cough 


Sharp  pain  in  left  chest  and  right 
arm.  Later  dyspncsa,  dulness  over 
base  of  left  lung,  fremitus  in  left  hy- 
pochondrium.  On  puncture  sanguin- 
olent  serum  containing  lymphocytes 
and  endothelium 

No  clinical  history  given  in  excerpt 


Cough,  dyspnoea,  night  sweats.  Fluid 
in  right  chest.  Clinical  signs  those 
of  chronic  phthisis,  especially  at  right 
apex.     Duration  11  months 


Cough  for  years;  after  a  cold  in- 
creasing cough,  dyspnoea  and  ema- 
ciation. Dulness  with  diminished 
bronchial  breathing  over  left  base 
gradually  extending  over  whole  of  left 
chest.  Aspiration  1500  c.c.  serous 
fluid  containing  fatty  epithelial  cells. 
Clinical  diagnosis:  malignant  neo- 
plasm of  pleura 

Dyspnoea,  pain;  left  apex  dulnesa 
and  bronchial  breathing.  Insomnia. 
Sudden  death  after  3  weeks 


_  Oppression,  pain;  signs  of  fluid  in 
right  chest.  Swelling  of  right  chest 
and  dilated  veins.  Flatness  with  faint 
and  distant  breathing.  Within  6 
weeks  4  tappings  of  chest  removing 
large  quantities  of  chocolate-colored 
fluid  containing  cancer  cells 


CARCINOMA 


151 


AUTOPSY    NOTES 


METASTASES 


MICROSCOPE 


None 


caseous  degeneration.  Left 
lung  adherent  to  thoracic 
wall  and  smaller  than  right. 
Nodules  in  lung  tissue;  cav- 
ities in  lower  lobe 


In  main  bronchus  of  right 
lung  circular  thickening  of 
mucous  membrane  which 
protrudes  into  lumen.  In 
substance  of  right  lung  large 
and  small  lumps  and  infil- 
trations of  grayish  color 


Mucoid,  no  Adeno-carcinoma  with 
tubercle  pronounced  mucoid  and  col- 
bacilli        loid  degeneration 


Not  men- 
tioned 


Profuse 


Mucoid, 
never 
bloody 


No  details 


No  details 


Bronchiectatic      cavities 
with     gelatinous      tumor 
masses  in  lungs,  also  bron- 
cho-pneumonic   foci    with 
cheesy  and  mucoid  degener- 
ation 


Large  portion  of  lower  right 
lobe  occupied  by  neoplasm 
which  is  very  soft.     Old  tu- 
bercular disease   of    both 
apices 

Carcinoma  of  left  main 
bronchus  with  destruction 
of  its  walls.  Irregular  tu- 
DQor  nodules  at  hilus  invad- 
ing lung  along  bronchial 
ramifications.  Suppurative 
pneumonia  of  entire  left 
lung.  Compression  of  tra- 
chea 

Bloody  fluid    in    both 
pleurae,  which   are  studded 
with  tumor  nodules.    Large 
medullary  tumor   at  left 
apex  ramifying  in  all  direc' 
tions.     Right  lung  healthy 


Right  lung  studded  with 
irregular  cancer  growths, 
especially  in   lower  part. 
Pleura  much  thickened,  can- 
cerous mass  in  lower  portion 
of   left   lung  compressing  a 
branch   of  the   pulmonary 
artery 


Bronchial 
and  retro- 
peritoneal 
lymph 
nodes, 
pleura  and 
peritoneum 

Pleura 


Pleura, 
bones,  brain 


Not  men- 
tioned 


Bronchial 
and  medias- 
tinal lymph 
nodes  and 
liver 


Pleura,  peri- 
cardium, in- 
terventricu- 
lar septum 
of  heart, 
diaphragm, 
liver  and 
left  kidney 

No  details 


eration.  Mu- 
coid degener- 
ation 


Polymor- 
phous epithe- 
lial cells  un- 
dergoing col- 
loid degener- 
ation 


Adeno-car- 
cinoma 


Medullary 
carcinoma 


No  details 


Direct  origin  from 
bronchial  mucous 
membrane  could  not 
be  established.  Au- 
thor thinks  it  prob- 
able that  tumor  was 
primary  in  lung 


Only  called 

"Mark- 

schwamm" 


No  details 


152 


TABLE   I 


NO. 

ATJTHOH 

SEX 

AGE 

LUNG    IN- 
VOLVED 

CLINICAL   SYMPTOMS 

114 

HiLLENBERG, 

Diss.  Kiel,  1893 
Ein  Fall  von  primarem 
Lungenkrebs 

M 

72 

L 

After  influenza,  pain  in  chest,  cough. 
Flatness  with  diminished  respiration 
over  left  apex  extending  downward. 
Some  dulness  over  right  apex;  later 
symptoms  of  cavity  in  left  apex. 
Some  tenderness  over  thoracic  ver- 
tebrse.  Clinical  diagnosis  tuberculosis. 
Duration  about  one  year 

115 

HiNTERSTOISSER, 

Wiener   klin.    Woch., 
1889,  II,  p.  374 
Ein  Fall  von  Karzinom 
der  grossen  Luftwege, 
etc. 

M 

69 

Always  well.  Contusion  of  chest 
from  fall  from  horse.  Shortly  there- 
after cough,  difficult  breathing,  hoarse- 
ness. Later  enlargement  of  various 
groups  of  lymph  nodes.  Dulness  over 
upper  portion  of  sternum  and  left  chest 
merging  into  heart  dulness.  Paralysis 
of  left  vocal  cord.  Painful,  hard 
swelling  tip  of  right  4th  finger.  Finger 
is  amputated.  Increasing  dyspnoea 
and  exhaustion.  Duration  about  one 
year 

116 

HiTZ, 

Diss.  Zurich,  1887 
Ein  Beitrag  zur  Casuis- 
tik  des  primaren 
Lungencarcinoms 

F 

40 

R 

No  heredity.  Syphilis  admitted. 
Fever,  cough,  emaciation.  Gradually 
increasing  symptoms  of  obstruction  of 
right  main  bronchus  but  no  other  evi- 
dence of  pulmonary  disease.  An  at- 
tack of  pneumonia  was  followed  for  a 
time  by  remarkable  improvement  of 
all  symptoms.  Later  increasing  dysp- 
noea, dysphagia,  pain  in  right  and  left 
chest,  cough,  oedoema.  Death  from  ex- 
haustion.    Duration  about  one  year 

117 

HOPMANN, 

Diss.  Zurich,   1893 
(after  Passler) 
tjber  malig.  Lungen- 
geschwiilste 

M 

36 

L 

Dyspnoea;  intense  pain  in  chest 

118 

Log.  cit. 

F 

56 

R 

Intense  dyspnoea 

119 

Horn,  Oscar, 

Virch.  Arch.,  Vol.  189, 

1907,  p.  414 
Ein  Fall  von  primarem 

Adeno-carcinom    der 

Lunge  mit  Cylinder- 

epithel. 

F 

18 

L 

About  4  years  before  death  dyspnceai 
pain  in  chest,  cough  and  expectoration. 
Tympanitic  note  on  left  chest  to  3rd 
rib;  increasing  dulness  below  with 
rales;  diminished  voice  and  breathing. 
Profuse  haemoptysis,  increasing  dysp- 
noea, cyanosis.     Sudden  death 

CARCINOMA 


153 


SPUTUM 

AUTOPSY    NOTES 

METASTASES 

MICROSCOPE 

EEMAKKS 

No  tubercle 

Large,   degenerating  car- 

Right lung 

Typical  cylin- 

bacilli 

cinoma  of  left  upper  lobe. 
Cancerous   and    pneumonic 
infiltration  of  left  lower  lobe 

and  spleen 

drical  celled 
carcinoma. 
Author  be- 
lieves origin 
to  be  from 
bronchial 
surface  epi- 
thelium 

Mucoid, 

Carcinoma  of  trachea  and 

Finger-tip, 

Typical 

Diagnosis  made 

often 

bronchi 

bronchial. 

carcinoma 

during-  life  from  spu- 

bloody. 

mediastinal. 

tum 

Contains 

cervical. 

numerous 

left  supra- 

epithelial 

clavicular, 

cells,  sin- 

right axil- 

gle and 

lary  and 

adherent 

lumbar 

in  groups 

lymph  nodes 

Mucoid, 

Right  main  bronchus  al- 

Regionary 

Alveolar 

often 

most  completely  obstructed 

lymph  nodes 

structure 

bloody, 

by  tumor  proliferating  into 

with  nests  of 

no  tuber- 

trachea.    Posterior  f  of 

large  poly- 

cle bacilli 

upper  lobe  infiltrated  with 

morphous 

or  tumor 

hard,  firm,  tumor;    numer- 

epithelial 

elements 

ous  bronchiectatic  cavities. 

cells 

ever 

Enormous  dilatation  of  left 

found 

lung 

None 

Large  medullary  tumor  of 

Not  men- 

Not men- 

entire left  lung.     Left  main 

tioned 

tioned 

bronchus    obstructed    and 

compressed.     Tumor  perfo- 

rates pulmonary  vein    and 

left    auricle.      Aorta    com- 

pressed.    Tumor    prolifer- 

ates into  body  of  some  of  the 

vertebrae 

Not  men- 

Medullary tumor  of  right 

Regionary 

Not  men- 

tioned 

main  bronchus  following 
its  ramifications   to   finest 
branches.     Proliferates   up- 
wards beyond  bifurcation 
and  into  left  bronchus 

lymph 
nodes,  both 
pleurae  and 
left  lung 

tioned 

Haemopty- 

Left main  bronchus  com- 

A few 

Glandular 

Origin    probably 

sis,  choc- 

pletely closed  by  tumor;  left 

glands  at 

structure; 

from    bronchial    mu- 

olate-col- 

lung collapsed.     Bronchi- 

hilus; no 

typical  cylin- 

cous membrane 

ored  and 

ectatic  cavities.     Out  of   a 

other  metas- 

drical celled 

foetid 

smaller  cavity  in  the  upper 

tases 

epithelium 

sputum, 

lobe    a  tumor  mass   grows 

with  basal 

no  tuber- 

from a  broad    pedicle  and 

membrane. 

cle  bacilli 

proliferates  into  one  of  the 
larger  upper  bronchi,  filling 
it  and  budding  into  a  num- 
ber of  smaller  bronchi 

cuticula  and 
cilia 

154 


TABLE   I 


120 


HOYLE, 

Jour.  Anat.  and 
Physiol.,  XVIII,  509 


Not 


LUNG    IN- 
VOLVED 


stated 


121 


122 


123 


124 


Hughes,  H.  Marshall, 
Guy's  Hospital  Re 
ports,VI,  1841,  p.  330 

Cases  of  Malignant  Dis 
ease  of  the  Lung 


Hellt, 

Zeitschr.f.Heilk.Vol. 

28,1907.    Path.  Anat 

p.  105 
Ein   seltener   primarer 

Lungentumor 


Heremann, 

Deut.    Arch.    f.    klin. 

Med.,Vol.63, 1899,  p. 

583 
Zur  Symptom,  u.  Diag. 

des     prim.     Lungen- 

krebses 


Log.  cit. 


M 


M 


50 


43 


36 


42 


R 


Both 


R 


R 


CLINICAL    SYMPTOMS 


Fever;  pain  in  right  side  of  back. 
No  definite  signs  on  lungs.  Death 
from  profuse  hsemoptysis 


No  heredity.  Always  healthy  until 
two  years  ago  when  caught  cold;  since 
then  occasional  attacks  of  haemoptysis. 
Cough,  dyspnoea.  Retraction  of  right 
chest  below  clavicle;  flatness,  in- 
creased fremitus,  tubular  breathing. 
Dilated  and  tortuous  veins  of  lower 
abdomen  and  right  chest.  (Edoema  of 
legs.  Enlarged  lymph  node  in  right 
axilla  and  below  right  clavicle.  Dura- 
tion about  2§  years 

111  for  one  year.  Physical  signs 
seem  to  point  to  tuberculosis.  Died 
before  full  examination  could  be  made 
at  hospital 


Jaundice,  oedoema  of  legs,"  enlarged 
right  supraclavicular  glands.  Dysp- 
noea; no  fever.  Dulness  and  dimin- 
ished voice  and  breathing  over  right 
apex.  Lungs  otherwise  normal.  En- 
larged nodulated  Uver.     Ascites 


Cough,  increasing  dyspnoea,  loss  of 
weight.  CEdoema  of  eyelids;  cyanosis; 
no  fever.  Flatness  and  absence  of 
voice  and  breathing  sounds  over  whole 
of  right  chest.  1500  c.c.  sero-purulent 
fluid  aspirated  without  diminishing 
dulness;  2  days  later  3000  c.c.  with 
the  same  result.  Repeated  aspira- 
tions large  quantities  hsemorrhagic 
serum.  Swelling  of  right  cervical 
glands.  Duration  of  disease  a  year 
and  half 


CARCINOMA 


155 


SPUTUM 

AUTOPSY    NOTES 

METASTASES 

MICROSCOPE 

REMABKS 

No  details 

In  upper  lobe  of  left  lung 

Cavity  in 

Epithelioma 

irregular  cavity  surrounded 

liver;  nod- 

with typical 

by  tumor 

ules  with 
soft    centres 
in  left  kid- 
ney, iliac 
fossa,  3rd 
dorsal  ver- 
tebra and 
5th  rib 

nests 

Bloody 

Entire  upper  lobe  of  right 

Lower  lobe, 

No  details 

Diagnosis  made 

lung  converted  into  medul- 

Uver, both 

during  life  on  general 

lary  tumor  with  strands  ex- 

kidneys, 

considerations 

tending  to  middle  lobe,  with 

right  supra- 

proliferation into  right  pul- 

renal 

monary  artery 

No  details 

Both  lungs  contained  nu- 

None.    Not 

Alveolar 

Evidently      malig- 

merous nodules  up  to  size 

a  single 

structure  of 

nant     and     therefore 

of    walnut    and    frequently 

lymph  node 

the  adenoma- 

classed   under    carci- 

confluent.      Boundary    be- 

enlarged or 

tous  type; 

noma  although  struc- 

tween tumor  and  lung  not 

any  sign  of 

high  cylindri- 

ture is  that  of  pure 

sharply  defined.     It  was  im- 

tumor 

cal,  non-cili- 

adenoma 

possible  at  autopsy  to  de- 

throughout 

ated  epithe- 

termine whether  it  was  tu- 

the body 

lium  with  oc- 

mor or  some  inflammatory 

casional  gob- 

process 

let  cells. 
Alveoli  filled 
with  coagu- 
lated mucoid 
material 

Jelly-like 

Tumor  at  root   of   right 

Bronchial 

Tjrpical  car- 

and 

lung    surrounding    bronchi ; 

lymph 

cinomatous 

bloody, 

one  large  bronchus  obstruct- 

nodes, both 

structure 

showing 

ed    by    medullary    tumor. 

lungs,  liver 

under  mi- 

Foetid bronchitis,  cirrhosis  of 

croscope 

[iver,  hypertrophic  and  fatty 

plates  of 

tieart,   interstitial    nephritis 

epithelial 

cells  from 

which  di- 

agnosis is 

made  dur- 

ing life 

Bloody 

Hard,  whitish-yellow  tu- 

Not men- 

Not men- 

expecto- 

mor size  of  a  hen's  egg  in 

tioned 

tioned 

ration 
2  days 
before 

region  of  right  hilua 

death 

156 


TABLE   I 


126 


126 


Loc.  CIT. 


LOC.   CIT. 


127 


128 


129 


130 


Loc.  CIT. 


Hereman, 
Diss.  Greifswald,  1895 
Ein  Fall  von  primarem 
Lungencarcinom 


HiLDEBRANDT, 

Diss.  Marburg,  1888 
(after  Passler) 
Zwei  Falle  von  prima- 
rem Lungentumor 


Hughes, 
Loc.  cit. 


M 


M 


M 


LTJNQ    IN- 
VOLVED 


51 


61 


56 


58 


43 


R 


R 


CLINICAL    SYMPTOMS 


No  heredity.  Sudden  pain  followed 
by  cough,  dyspnoea,  dysphagia,  hoarse- 
ness, loss  of  weight.  Flatness  with  ab- 
sence of  voice  and  breathing  over  whole 
of  left  chest.  Hard  supraclavicular 
glands.     Aspiration:  bloody  fluid 

No  heredity.  On  admission  com- 
plains of  rheumatism  and  emaciation. 
There  is  some  emphysema  and  bron- 
chitis; symptoms  of  alcoholic  neuritis; 
clubbed  fingers.  Nothing  points  to 
disease  of  lungs.  Two  weeks  before 
death  for  the  first  time  dulness  over 
left  upper  lobe  with  diminished  breath- 
ing; later  absolute  flatness  over  entire 
left  upper  lobe.  Some  swollen  cervi- 
cal glands 


Increasing  emaciation  and  cachexia. 
Hoarseness;  flatness  with  diminished 
breathing  over  left  apex.  Enlarged 
nodular  liver;  absence  of  free  HCl 
in  stomach 

Father  and  sister  died  _  of  cancer. 
Increasing  dyspnoea,  rapid  loss  of 
strength,  pain  in  left  chest,  oedcema  of 
legs,  dilated  veins  of  neck.  Impaired 
mobility  of  left  chest.  Absolute  flat- 
ness with  bronchial  and  almost  am- 
phoric breathing  over  whole  of  left 
chest  except  apex.  Dislocation  of  heart 
to  right.  Chocolate-colored  fluid  in  left 
chest.  Duration  of  illness  about  one 
year 

Not  given 


Always  healthy.  First  sjrmptoms 
incontinence  of  urine  and  oedcema  of 
legs.  Later  severe  pain  in  right  chest; 
cough.  On  admission,  oedcema  of  legs, 
right  arm,  and  chest  and  puffiness 
of  face.  Clubbed  fingers.  Dulness 
over  right  chest;  absence  of  breathing 
sounds.     Heart  pushed  to  left.    Aspi- 


CARCINOMA 


157 


SPUTUM 

AUTOPSY   NOTES 

METASTASES 

MICROSCOPE 

REMARKS 

Mucopuru- 

Hard tumor  starting  from 

Bronchial 

Not  men- 

lent, no 

hilus  and   surrounding  and 

and  mesen- 

tioned 

tubercle 

following   bronchial   ramifi- 

teric lymph 

bacilli 

cations 

nodes,  liver 
and  kidneys 

Often 

Soft  tumor  in  left  upper 

Lung,  ven- 

Not men- 

bloody; 

lobe,  starting  from  hilus  and 

tricular  sep- 

tioned 

under  mi- 

containing cavity 

tum  of 

croscope 

heart,  thy- 

great 

roid,  left 

numbers 

kidney,  left 

of  large, 

suprarenal 

fatty,  flat 

and  poly- 

morph- 

ous epi- 

thelial 

cells,  no 

tubercle 

bacilli. 

From 

this  and 

cachexia 

and  ema- 

ciation 

diagnosis 

was  made 

during  life 

Mucopuru- 

Cancer of  apex  of  left  lung 

Right  lung. 

Not  men- 

lent, no 

liver,  mesen- 

tioned 

tubercle 

teric  lymph 

bacilli 

nodes 

Scant,  not 

Left  main  bronchus  leads 

Secondary 

Pavement 

bloody 

into   soft   medullary  tumor 

nodules  in 

epithelium 

of  left  lower  lobe  and  along 

right  pleura 

with  cell- 

bronchial    ramifications    to 

nests 

hilus.     Entire  left  lung  ate- 

lectatic.    Encapsulated 

bloody  effusion  in  pleura 

Not  given 

Medullary   carcinoma   of 
right  main  bronchus  slightly 
infiltrating  surrounding  tis- 
sue.    Carcinomatous    infil- 
tration   of  right  subpleural 
lymphatics 

Pleura 

Cylindrical 
and  polyhe- 
dral cells 

Currant 

Whole  of  right  lung  occu- 

Not men- 

Not men- 

Diagnosis made  dur- 

jelly 

pied  by  fungus   mass   con- 
taining irregular  cavity  in 
centre 

tioned 

tioned 

ing  life  from  cedcema 
of     right     arm     and 
bloody  sputum  after 
exclusion  of  empyema 

158 


TABLE   I 


131 


132 


133 


134 


135 


136 


Hyde,  Salter, 

London  Lancet,  1869, 
II,  July  3,  p.  10 

Primary  Cancer   of   the 
Lung 


Jaccotjd, 

Legons  de  Clin.  M6d. 

1871-72,  p.  454 
Cancer  de  Poumon 


Japha, 

..  Diss.  Berlin,  1892 
tjber     primaren     Lun- 
genkrebs 


Log.  ciT. 


Loo.  CIT. 


Log.  CIT. 


M 


M 


M 


M 


M 


M 


43 


50 


49 


48 


51 


58 


LUNG    IN- 
VOLVED 


R 


R 


R 


R 


CLINICAL    STMPTOMS 


ration    negative, 
months 


Duration    about  6 


Always  healthy.  Swelling  of  neck 
and  face  several  months  before  any 
other  symptoms;  then  sHght  dyspnoea, 
dilatation  of  superficial  veins  of  chest 
and  upper  part  of  body.  Later  cough, 
rapid  loss  of  strength,  hoarseness, 
laryngeal  cough.  Complete  dulness 
in  front  almost  to  base;  behind  to 
angle  of  scapula.  Bronchial  respira- 
tion; no  rales.  Later  cyanosis;  absence 
of  voice  and  breathing  sounds 

No  heredity.  Cough  for  some  years. 
Slight  oppression  on  right  chest.  In- 
creasing loss  of  strength  and  flesh. 
Later  dyspnoea,  cough,  pain  in  right 
chest.  Dulness  on  right  lung  from 
base  to  angle  of  scapula;  diminished 
voice  and  breathing.  Flatness  in  re- 
gion of  hilus  with  bronchial  respira- 
tion.    Diagnosis  made  during  life 


Fever,  pain  in  chest,  cough.  Dulness 
over  right  upper  lobe;  clubbed  fingers. 
Later  symptoms  cavity  right  apex. 
Emaciation 


Dyspnoea,  pain,  cyanosis;  pleuritic 
effusion.  Several  aspirations  yield 
large  quantities  of  clear  senim,  later 
bloody  or  chocolate-brown.  Dilata- 
tion of  veins  of  chest 


Severe  dyspnoea,  distress  in  stomach ; 
pain  in  left  chest.  Flatness  over  left 
chest  with  symptoms  of  pleuritic 
effusion.  Repeated  aspirations  yield 
brown  fluid.  Increasing  cachexia; 
enormous  dyspnoea 

Pain  in  right  chest;  pleuritic  effu- 
sion. Increasing  debility  and  brady- 
cardia. Dulness  right  upper  lobe  with 
diminished  respiration.  Ulcerating  tu- 
mor skin  of  abdomen.  Swelling  of 
head   of  right   humerus 


CARCINOMA 


159 


SPUTUM 

AUTOPSY    NOTES 

METASTASES 

MICROSCOPE 

KEMAKKS 

Often  pro- 

Nearly whole  of  right  lung 

_  Not  men- 

Not men- 

Diagnosis made 

fuse  and 

converted  into  "encephaloid 

tioned 

tioned 

during  life 

bloody, 

cancer."     Heart  pushed  al- 

contain- 

most   horizontal.       Almost 

ing  pecu- 

complete compression  of  up- 

liar heavy 

per  cava.     Compression  of 

pellets 

trachea  and  right  main  bron- 
chus.    Cavities  and  soften- 
ing in  various  places 

Bloody, 

Voluminous  mass  of  "en- 

Right lung, 

No  details 

Clinical  diagnosis  ol 

several 

cephaloid  cancer  "  at  right 

pleurae,  peri- 

tumor of  lung  made 

hffimop- 

hilus,  penetrating  lung  and 

cardium. 

during  life  from  analy- 

tyses 

connecting    with    bronchial 

around  ori- 

sis  of  physical    signs 

glands.     Bronchi    and    ves- 

gin of  aorta 

and  exclusion  of  other 

sels   throughout   tumor  en- 

and pulmon- 

possibilities 

veloped,  but  not  compressed 

ary  artery 

by  neoplasm.     Bloody  effu- 

and vein; 

sion  in  pericardium 

liver,  dura 
eroding  into 
bone  and 
reaching  in- 
to temporal 
muscle 

Occasion- 

Medullary    tumor     with 

Single 

Very  large 

ally 

cavity  in  right  upper  lobe; 

lymph  node 

epithelial 

bloody. 

bronchiectatic  cavities 

cells  like 

no  tuber- 

pavement 

cle  bacilli 

cells,  but 

but  elas- 

author con- 

tic fibres 

siders  alveo- 

and pig- 

lar epithe- 

ment 

lium  as  start- 
ing point 

Bloody,  no 

Tumor  from  hilus  follow- 

Lymph 

Cylindrical 

tubercle 

ing  along  bronchial  ramifi- 

nodes. 

and  pave- 

bacilli, 

cations  in  right  lower  lobe. 

pleura  and 

ment  epithe- 

later 

Complete       conversion      of 

pericardium 

lium  originat- 

distinct 

bronchial    wall   into     carci- 

ing from 

cancer 

noma 

bronchial 

particles 

mucous  mem- 
brane 

Haemor- 

Tumor  in  left  lower  lobe. 

Right   lung, 

Cylindrical 

rhagic 

Left  lung  dislocated  and  com- 

both pleurae, 

celled  carci- 

pressed by  several  quarts  of 

regionary 

noma  prob- 

fluid.    Pleura  thickened 

lymph 
nodes,  liver 
and  spleen 

ably  originat- 
ing from  bron- 
chial wall 

Bloody,  no 

Tumor  of  right  upper  lobe 

Right 

Flat  pave- 

Diagnosis  was 

tubercle 

with  necrotic  ca^dties  com- 

pleura, liver  ment  epithe- 

made  during  life 

bacilli 

municating  with  bronchi 

diaphragm,    Hum  with 

right  hu- 

typical can- 

merus, skin 

cer  nests. 

of  abdomen 

Author  con- 
siders alveo- 
lar epithe- 
lium as  origin 

160 


TABLE   I 


137 


138 


139 


140 


141 


Jessen, 

Zentralbl.  f .  inn.  Med., 
Jan.  1906,  No.  1 

Ein  Fall  von  Karzinom 
und  Tuberkulose  der 
Lunge  intravitam  di- 
agnostiziert 


JosEFsoN,   Arnold, 
.    Hygiea,  1903,  Ht.  2, 
p.     139.     Zeitschr.   f. 
Krebsforschung, 
1904,    I,    p.   372. 
Schmidts  Jahrb.,  Vol, 
280,  p.   220,    1903. 
Primares    Lungen- 
carcinom 


Kappis,  Max, 

Munch.  Med.  Wo- 
chensch,  1907,  No.  18, 
p.  88 

Hochgradige  Eosinophi- 
lie  des  Blutes  bei  ei- 
nem  malignen  Tumor 
der  rechten  Lunge 


Karminsky, 

Diss.  Greifswald,  1898 

(after  Cohn) 
Primares    Lungencarci- 

nom  mit  verhornten 

Plattenepithelien 


EIarrenstein, 

Charitfe  Annalen,  Vol. 
32,  1908,  p.  315 

Ein  Fall  von  Kancroid 
eines  Bronchus  und 
Kasuistisches  zur 
Frage  des  primaren 
Bronchial-  und  Lun 
genkrebses 


M 


M 


M 


M 


M 


45 


77 


69 


51 


48 


LUNG    IN- 
VOLVED 


R 


L(?) 


R 


R 


CLINICAL    SYMPTOMS 


Heredity  of  tuberculosis;  active 
symptoms  of  tuberculosis.  Tubercu- 
lar cavity  of  right  upper  lobe.  After 
treatment  at  Davos,  bacilli  disappeared 
from  sputum  and  tubercular  process 
seemed  arrested.  Slight  elevation  of 
temperature  and  dry  cough  continues. 
Progressive  area  of  absolute  flatness 
in  lower  right  lung.  Dyspnoea;  symp- 
toms of  bronchial  obstruction;  cedcema 
of  legs,  dilatation  of  superficial  veins. 
Increasing  cachexia;  death  from  suf- 
focation. Clinical  diagnosis:  cica- 
trized tuberculosis  of  lungs,  tubercular 
cavity  of  right  apex;  carcinoma  of 
right   lung   or   pleura 

Loss  of  appetite,  emaciation,  per- 
sistent cough.  Left  lung  posteriorly 
dulness;  diminished  respiration  and 
fremitus.     Effusion    in   left   pleura 


No  heredity.  Increasing  debility 
and  _  emaciation;  harassing  cough, 
effusion  in  right  chest.  Heart  dis- 
located to  right.  Aspiration  yields 
bloody  serum.  Dulness  with  loss  of 
breathing  and  voice  sounds.  Left  lung 
normal.  No  reaction  with  tuberculin. 
Blood:  hemoglobin  120;  reds  6,200,000; 
whites  50,560-40,700;  polynuclears 
56.9;  eosinophiles  33-39.5%.  Aspira- 
tion: sanguinolent  serum  without  eosin- 
ophiles.   Eosinophilia  not  explained 


No  clinical  history 


Haemoptysis.  Pain  in  right  chest, 
gradual  loss  of  weight  and  strength. 
Dulness  over  anterior  aspect  of  right 
lung.  Bronchoscope  showed  promi- 
nent tumor  in  right  bronchus,  com- 
pressing it,  from  which  clinical  diag- 
nosis of  tumor  of  lung  was  made. 
Duration  of  disease  about  10  months 


CARCINOMA 


161 


SPUTUM 

AUTOPSY    NOTES 

METASTASES 

MICBOSCOPE 

HEMAKKS 

Tubercle 

Tubercular  cicatrizations 

Wall  of 

Scirrhus 

bacilli 

left  lung;   tubercular  cavity 

right  ven- 

with squa- 

right apex.      In  lower   por- 

tricle 

mous  epithe- 

tion right  upper  lobe   firm. 

lium 

fibrous  carcinoma.     Tumor 

surrounds  large  vessels  and 

is  supposed  to  originate  from 

hilus 

Raspberry 

No  record,  merely  stated 

No  details 

No  details 

Diagnosis   on  basis 

jelly. 

that  in  centrifuged  pleuritic 

of  sputum  made  intra 

Cancer 

effusion   cancer    cells    with 

vitam.     Author    cas- 

cells with 

mitosis  were  found 

ually    mentions    that 

mitosis 

since   1897  there    oc- 
curred in  Sabbatsberg 
Krankrenhaus      10 
other  cases  in   which 
autopsy  showed  pri- 
mary cancer  of  lung 

Scant,  mu- 

Large carcinoma  in  right 

Lymph 

Alveolar 

Enormous  heaping 

coid,  no 

lower  lobe  adherent  to  chest 

nodes  at 

structure ; 

of  eosinophiles  where 

tubercle 

wall,   diaphragm,  and    peri- 

hilus and 

large  polyg- 

there is  no  tumor 

bacilli 

cardium.     Pneumonic  infil- 

around 

onal  epithe- 

tration around  tumor  with 

aorta;  in 

lium 

necrosis  in  centre 

sternum, 
dorsal  ver- 
tebrae, ribs, 
liver,  left 
adrenal 

No  details 

Tumor  with  cavity  in  left 

Two  sec- 

Typical 

upper  lobe  involving  afferent 

ondary  nod- 

horny can- 

bronchus 

ules  in  left 
upper  lobe. 
Bronchial 
lymph 
nodes,  left 
pleura,  left 
kidney,  left 
adrenal  and 
ventricular 
septum  of 
heart 

croid 

Haemopty- 

Right upper  and  middle 

Liver,  stom- 

Typical can- 

All metastases  have 

sis 

lobes  almost  completely  con- 

ach, kid- 

croid with 

structure     similar    to 

verted  into  tumor  with  soft- 

neys,  brain. 

pavement 

that    of    original    tu- 

ening    in    centre.     Growth 

pericardium 

epithelial 

mor,     except     metas- 

takes origin  in  large  bron- 

cells, horny 

tases    in  brain;    here 

chus  immediately  below  first 

and  prickle 

they  have  no   horny 

division  of  right  main  bron- 

cells and  cell 

or   prickle    cells,    but 

chus  where  wall  of  bronchus 

nests.   _  Prob- 

cells   are    cylindrical 

is  infiltrated  and  penetrated 

able  origin 

and   in    lower    layers 

by  neoplasm 

from  super- 

polygonal,  and  tumor 

12 


162 


TABLE   I 


NO. 

AXJTHOK 

SEX 

AGE 

LTJNG    IN- 
VOLVED 

CLINICAL    STMPTOMS 

142 

Kasem-Beck, 

Centralbl.  f .  inn.  Med. 
1898 

M 

57 

L 

Dyspnoea,  cough,  slight  fever,  pain 
in  left  chest.  Later  severe  chills. 
Dulness  over  upper  portion  left  chest. 
Bronchial  breathing 

143 

Log.  cit. 

M 

60 

L 

Cough,  dyspnoea,  diminished  expan- 
sion of  left  chest,  dilated  superficial 
veins,  enlarged  axillary  glands.  Dul- 
ness from  left  axilla  downward ;  dimin- 
ished voice  and  breathing;  tenderness 

144 

KiDD, 

St.    Bartholomew's 
Hospital     Reports, 
1883,   XIX,   227-234 
A  Case  of  Primary  Ma- 
lignant Disease  of  the 
Lung 

M 

36 

R 

Pain  in  right  chest,  cough,  clubbed 
fingers;  bulging  of  right  chest.  Di- 
minished respiratory  movements  and 
breathing  sounds;  flatness.  Left  side 
normal.  Aspiration:  scant,  thin,  gru- 
mous  fluid.  Hectic  temperature,  dysp- 
noea, ansemia.  Duration  about  8 
months 

145 

Klubeb, 

Diss.  Erlangen,  1898 
Ein  Fall  von  Bronchial- 

carcinom    und    Lun- 

gencyste 

F 

34 

R 

Apparently  healthy  woman.  Sud- 
den death  from  extensive  burn 

146 

Kniehiem, 

Verhandl.       deutsch. 

pathol.    Gesellschaft, 
..  1909,  p.  407 
Uber    ein    primares 

Lungenkarzinom 

F 

59 

R 

No  clinical  history.  Admitted  mori- 
bund and  died  same  day 

CARCINOMA 


163 


SPUTUM 

AUTOPSY  NOTES 

METASTASES 

MICROSCOPE 

REMABKS 

ficial  bron- 

has distinct  papillary 

chial  epithe- 

structure. Author  has 

lium 

some  doubt  if  this  is 
genuine  metastasis  or 
a      second      primary 
tumor   in  brain 

Mucoid 

Primary  tumor  left  upper 
lobe 

None 

No  details 

No  blood 

Diffuse  cancerous  infiltra- 

Bronchial 

"Carcinoma 

tion  in  lower  f  of  left  lung; 

lymph 

simplex" 

disseminated  nodules  in  up- 

nodes, 

per  third 

pleura, 
liver,  head 
of  pancreas 

Currant 

Greater  portion  of  right 

Posterior 

"Encepha- 

jelly. 

lung  converted  into  tumor, 

mediastinal, 

loid  cancer" 

some 

consisting  of  white,  nodular 

axillary  and 

haemop- 

masses;  small  cavities  in  up- 

retroperito- 

tysis 

per  and  middle  lobes.     Sec- 
ondary bronchi  much  com- 
pressed.    Margin  of  pleura 
over  right  lobe  thickened  and 
of  medullary  appearance 

neal  lymph 
nodes 

None 

Medullary    white    tumor 
completely  obstructing  right 
lower  main  bronchus,  caus- 
ing large  bronchiectatic  cyst 
in  right  lower  lobe 

None 

Glandular 
alveolar 
structure ; 
small  cu- 
boidal  epithe- 
lial cells. 
Origin  from 
bronchial 
mucous 
glands 

No  details 

Large  quantity  clear  se- 

Lsnmph 

Two  differ- 

rum in  right   pleura;    right 

nodes  of 

ent  types — 

lung  adherent.     Under  pul- 

right hilus; 

one,  distinct 

monary  pleura  tumor  infil- 

retroperi- 

alveoles lined 

tration   following  the   lym- 

toneal and 

with  cylindri- 

phatics.    Middle  and  lower 

retrogastric 

cal  cells,  and 

lobe  filled  with  diffuse  gray 

lymph 

the  other. 

tumor    masses;     numerous 

nodes 

patches  con- 

discrete and  confluent  nod- 

sisting of 

ules  in   near  vicinity.     All 

large,  irregu- 

through   the    lung    miliary 

lar  polygonal 

gray  nodules  between    the 

cells  arranged 

alveoli    filled   with    mucus. 

in  more  solid 

Left  lung  healthy 

masses.   Pap- 
illary projec- 
tions prolifer- 
ate into  the 
alveoli; 
transition 
from  flat  al- 
veolar epithe- 
lium to  cubic 
and  high  cy- 

164 


TABLE   I 


147 


148 


149 


150 


KoHNER, 

Miinchener     Med. 
Wochenschr.,    1888, 
No.  11 
Ein  Fall  von  primarem 
Krebs     der     grossen 
Luftwege,  etc. 


Khatz, 

Diss.  Miinchen,  1892 
..  (after  Angelhoff) 
tjber  ein  Fail  von  pri- 
marem Lungencarci- 
nom  mit  Metastasen 
im  Gehirn 

Khetschmeh, 

Diss.     Leipzig,     1904 
Uber     das     primare 

Bronchial-  und   Lun- 

genkarzinom 


Log.  cit. 


M 


M 


M 


M 


64 


38 


44 


56 


LUNG    IN- 
VOLVED 


R 


CLINICAL    SYMPTOMS 


Cough,  oppression  in  chest;  flatten- 
ing of  right  chest  wall.  All  symptoms 
of  complete  and  uncomplicated  obstruc- 
tion of  right  main  bronchus,  absolute 
flatness,  absence  of  respiratory  and 
voice  sounds.  Diagnosis  made  during 
life 


For  several  months  dizziness,  pain 
in  head  and  chest.  Choked  disc  both 
eyes;  headache,  vomiting.  Slight  dysp- 
noea. Nothing  found  on  lungs.  Clini- 
cal diagnosis:  tumor  of  brain 


Paralysis  of  recurrent;  consolida- 
tion and  secondary  gangrene  _  of  left 
lung;  cavities  and  bronchiectasis;  tem- 
porary closure  of  bronchus.  Clinical 
diagnosis:  neoplasm  of  lung 


Clinical  diagnosis:  pulmonary  tuber- 
culosis; pleurisy  with  effusion  in  left 
chest 


CARCINOMA 


165 


AUTOPSY    NOTES 


METASTASES 


MICROSCOPE 


Mucoid  cyl- 
inders 
with  co- 
agulated 
blood  in 
centre ; 
raspberry 
jelly;   oc- 
casional 
hsemop- 
tysis ; 
typical 
bronchial 
casts 

None 


No  details 


No  details 


Complete  obstruction  of 
right  main  bronchus  by  tu 
mor 


Large  carcinoma  in  left 
lower  lobe 


Bronchial  carcinoma  up- 
per left  lobe.     Gangrene  left 
upper  lobe;  almost  complete 
obliteration  left  pulmonary 
artery.     Carcinomatous  in 
filtration     of     pericardium ; 
carcinomatous  degeneration 
left  vagus;     ulcerated  can 
cerous  masses  in  upper  left 
main  bronchus 

Almost  entire  left  lower 
lobe  occupied  by  large  neo- 
plasm infiltrating  surround 
ing  tissue  and  spreading 
from  central  nodule.     Wall 


Tracheal 
and  bron- 
chial IjTuph 
nodes;  both 
right  pul- 
monary 
veins 


Both  lungs 
regionary 
lymph  nodes 
and  brain 


Pericar- 
dium; left 
vagus 


Left  frontal 
bone,  left 
kidney,  left 
suprarenal 


lindrical  cells. 
Large  and 
small  alveo- 
lar spaces 
filled  with 
granular  ten- 
acious mucus, 
often  con- 
taining flat  or 
round  and 
polygonal 
cells.  Larger 
bronchi  show 
no  lesions. 
Lymph  chan- 
nels in  walls 
of  lungs  and 
bronchi  con- 
tain    large 
carcinoma 
cells.    Origin, 
epithelium  of 
alveoli  and 
bronchioles 

Carcinoma 


No  details 


Alveolar 
structure, 
scirrhous 
stroma ;   cell 
nests  and 
pearls 


Similar  to 
preceding 


Bronchial  mucous 
glands  designated  as 
probable  origin 


166 


TABLE   I 


151 


152 


Loc.  CIT. 


Log.  CIT. 


153 


154 


155 


156 


167 


Loc.    CIT. 


Loc.   CIT. 


Kkiegsmann, 

Leipzig  Klinik,    1877 
(after  Reinhard) 


Kttbb, 

Centralbl.  f .  inn.Med., 

1906,  No.  44 
Primares    tracheobron- 

chogenes      Karzinom 

(Bohemian) 


KUHN, 

..  Diss.  Zurich,   1904 
Uber  maligne   Lungen- 
geschwiilste 


M 


M 


M 


M 


M 


67 


68 


45 


44 


69 


36 


LUNG    IN- 
VOLVED 


CLINICAL    SYMPTOMS 


Clinical  diagnosis:  purulent  bron- 
chitis, bronchiectasis,  pleurisy,  and 
diabetes 


Effusion  in  left  chest.  First  aspira- 
tion clear  serum;  second,  bloody 
serum 


R 


L(?) 


R 


69 


R 


Admitted    moribund.     No    clinical 
diagnosis 


Chronic    pneumonia,    hydrothorax, 
and  suspected  tumor  of  left  lung 


Pain  in  region  of  liver.  Cough, 
chills,  fever,  anorexia,  emaciation. 
Dulness  from  5th  rib  downward  with 
absence  of  voice  and  breathing 


Pain  in  chest,  obstinate  cough, 
dyspnoea,  rapid  cachexia  with  good 
appetite 


No  heredity.  Alcoholic  dementia. 
Hoarseness  with  paralysis  of  left  vocal 
cord;  dyspnoea,  dysphagia,  stridorous 
breathing,  emaciation,  and  cachexia. 
Dulness  over  right  apex  with  dimin- 
ished voice  and  breathing 


CARCINOMA 


167 


AUTOPSY    NOTES 


METASTASES     MICROSCOPE 


No  details 


No  details 


No  details 


No  details 


Purulent 
with  oc- 
casional 
haemor- 
rhage 


No  details 


of  left  lower  bronchus  in- 
filtrated with  cancerous  ma- 
terial, ulcerating  into  lumen 

Wall  of  left  lower  bron- 
chus destroyed  by  tumor  in- 
filtrating left  lower  lobe. 
Chronic  fibrous  pneumonia 
and  abscess  of  left  lung; 
chronic  fibrous  pleurisy 

Uneven  nodiilar  tumor  in 
left  main  bronchus;  entire 
anterior  portion  of  left  lung 
occupied  by  intensely  firm, 
nodiilar  tumor.  Bloody  se- 
nmi  in  left,  clear  senim  in 
right  pleura 


Large  portion  of  anterior 
aspect  of  right  lung  infil- 
trated with  thick,  firm  tu- 
mor extending  to  4th,  5th, 
and  6th  dorsal  vertebrae. 
Wall  of  right  main  bronchus 
contains  nodulated,  partly 
ulcerated  tumor  masses 
merging  into  lung  tumor 


None 


Mucopuru- 
lent ;  no 
blood,  no 
tubercle 
bacilli 


Bronchial, 
mediastinal, 
retroperito- 
neal lymph 
nodes;  left 
kidney, 
liver,  both 
suprarenals. 
(No  bronzed 
skin) 

Bones  of 
skull,  verte 
brse,  cerebel- 
lum, thy- 
roid, myo 
cardium, 
liver,  and 
kidneys 


Heart  dislocated  to  right; 
fluid  in  left  pleura,  which  is 
studded  with  tumor  nodules. 
Left  lung  everywhere  infil- 
trated with  soft  tumor. 
Similar  infiltrations  in  right 
liing  with  bronchiectases 

Right  lung  except  a  small 
part  of  upper  lobe  com- 
pletely consolidated.  Tumor 
masses  surround  end  of  tra- 
chea and  right  bronchus,  the 
latter  much  thickened,  infil- 
trated, and  compressed 

Carcinoma  originating 
from  mucous  membrane  of 
trachea  and  bronchi,  extend 
ing  along  ramifications  re- 
placing bronchial  mucous 
membrane  and  obstructing 
lumen 

Large  tumor  in  upper  right 
lobe  infiltrating  surrounding 
lung  tissue;  smaller  tumor 
compressing  oesophagus  and 
trachea.  Other  organs  with- 
out lesions 


Alveolar 

structure 


Adenomatous 
structiire 


Origin  from   bron- 
chial mucous  glands 


Origin  from  bron- 
chial mucous  glands 
can  be  demonstrated 


Pleura, 
pericardium 


Regionary 
lymph  nodes 
and  right 
lobe  of  liver 


No  details 
except  diag- 
nosis made 
from  metas- 
tases 


No  others 


Alveolar 
structure 
with  pave- 
ment epithe- 
lium; cuboid 
and  cylin- 
drical epi- 
thelium in 
periphery  of 
alveoli 

Alveolar 
and  papillary 
structure. 
Cylindrical 
cells 


No  details 


Origin    probably 
surface  epithelium  of 
bronchus 


Cylindrical 
cells 


No  details 
given 


Origin    probably 
from  alveolar  epithe- 
lium 


168 


T.IBLE   I 


158  KUSSMAUL, 

Berlin  klin.  Wochen- 
schr.  1879,  413-433 
Primares     Lungenkar- 
zinom  ohne  Metasta- 
sen 


159 


160 


161 


162 


163 


Labb6,    Makcel       et 

BOIDIN, 

Bull,  et  Mem.  Soc. 
Anatom.  de  Paris, 
1903,  No.  8,  pp.  743- 
747 
Carcinome  alveolaire 
cystique  du  Poumon 


Lammerhirt, 

Diss.  Greifswald,  1901 
Zur   Casuistik  des  pri- 

maren     Lungencarci- 

noms 


Log.  cit. 


M 


M 


M 


M 


60 


49 


LUNG 
INVOLVED 


CLINICAL   SYMPTOMS 


51 


51 


Laifle, 

Diss.  Munchen,  1895 
Uber     einen     Fall    von 

Mediastinal  und  Lun- 

gencarcinom 


Lanceratjx, 

Bull,   des  Soc.  Anat. 
de    Paris,     1858, 
XXXIII,  515-520 


164 


Lange, 

Memorabilien, 
No.  3 


1866, 


M 


M 


37 


49 


63 


R 


R 


R 


Blow  on  left  thorax.  7  weeks  there- 
after cough,  pain  in  region  of  injury. 
7  months  later  increasing  debility 
and  dyspnoea.  Lower  half  of  thorax 
in  front,  flat.  Intercostal  spaces  re- 
tracted. Left  thorax  anteriorly  flat- 
ness, absence  of  breathing 


First  complaint  15  hours  before 
admission  to  hospital.  Only  cerebral 
symptoms  —  headache  and  vomiting; 
slight  congestion  of  optic  discs.  Clini- 
cal diagnosis:  cerebellar  tumor.  Dura- 
tion about  2  weeks 


No  heredity.  Slight  headaches; 
otherwise  healthy.  Four  apoplectic 
seizures.  Pain  in  chest;  impaired  res- 
piratory motion  of  right  chest;  dul- 
ness  over  right  base;  no  auscultatory 
signs.  Clinical  diagnosis:  tumor  of 
brain 


Kick  on  left  chest;  some  months 
thereafter  weakness  and  cough.  Some 
weeks  later  kick  on  right  chest  followed 
by  sugillation,  cough,  bloody  expecto- 
ration, local  tenderness  and  fever.  In- 
creasing pain;  haemoptysis.  Dulness 
over  anterior  right  chest;  diminished 
voice  and  breathing 

Dyspnoea;  oedoema  of  face  and  neck. 
At  first  nothing  on  lungs ;  later  dulness 
over  right  middle  lobe  with  abolished 
breathing  sounds.  Fever,  night  sweats. 
Later  respiratory  immobility  of  right 
chest;  absolute  flatness  over  entire 
right  chest  in  front.  Cyanosis.  Ex- 
ploratory puncture  negative.  X-ray 
shows  deep  shadows  all  through  right 
lung 

DyspncEa,  cough,  cachexia.  _  Left 
apex  anteriorly  flatness;  no  voice  or 
breathing  sounds 


Sudden  attacks  of  suffocation;  in- 
tense irritation  in  throat;  rapid  ca- 
chexia. Dulness  over  right  side  with 
absence  of  breathing  and  voice  sounds. 


CARCINOMA 


169 


SPUTUM 

AUTOPSY   NOTES 

METASTASES 

MICROSCOPE 

EEMAEKS 

Occasion- 

Mediastinum   and    heart 

Absolutely 

Medullary 

ally  bron- 

displaced    towards      right. 

none 

carcinoma 

chial 

Left  upper  lobe  almost  en- 

with alveolar 

bloody 

tirely     occupied     by    large 

structure 

casts;  no 

tumor.     Aorta  adherent  to 

cancer 

but  not  compressed  by  tu- 

cells or 

mor.     Bronchi    obstructed; 

tubercle 

bronchiectases.      Left   pul- 

bacilli 

monary  artery  compressed 

None 

Large  cyst  in  left  cerebel- 

Glands of 

Alveolar 

lar  lobe  filled  with  fluid  con- 

hilus 

structure ; 

taining   numerous   lympho- 

polyhedral 

cytes.     One  large  and  many 

epithelium 

smaller  cavities  throughout 

right  upper  lobe.     Walls  of 

cavities  and  cyst  formed  of 

t 

cancerous    material.    Areas 

of  pulmonic  sclerosis  around 

cancerous  tissue.     All  other 

organs  healthy 

Scant,  not 

Carcinoma  of  right  lower 

Bronchial, 

Alveolar 

charac- 

lobe 

mediastinal 

structure ; 

teristic 

and  mesen- 
teric lymph 
nodes ;   nod- 
ules in  brain 
and  cerebel- 
lum 

cylindrical 
and  cuboid 
cells 

Bloody 

Carcinoma  of  right  lower 

Right 

Pavement 

lobe  and  5th  rib 

middle  lobe, 
bronchial 
and  supra- 
clavicular 
lymph  nodes 

epithelium 

Occasion- 

Tumor  nodules  in   right 

Peribron- 

None given 

aUy 

upper  lobe;    bronchiectatic 

chial,  tra- 

bloody, 

cavities.     At   bifurcation   a 

cheal,  and 

no  tuber- 

nodule extending  into  right 

mediastinal 

cle  bacilli 

and  left  main  bronchi  ob- 
structing lumina.  Compres- 
sion of  upper  cava 

lymph 
nodes,  liver, 
right  kidney 
and  mesen- 
teric glands 

Abundant, 

Left  lung  converted  into 

Left 

Not  given 

mucoid; 

"jelly-like"  mass.     Dilated 

lower  lobe, 

occasion- 

thoracic    veins;     cancerous 

right  lung, 

ally  blood 

thrombus  in  aorta 

liver,  kid- 

and 

neys,  supra- 

"brain- 

clavicular 

like"  suh- 

glands 

stance 

None 

Numerous  cancer  nodes  in 
right  lung;    some  softening. 
Large  cavity  at  apex.     Can- 
cer nodule  on  superior  cava. 

Right  testi- 
cle 

Not  given 

170 


TABLE   I 


165 


166 


167 


168 


169 


170 


171 


Langhans, 

Virchows     Archiv. 

1871,  LIII,  p.  470 
Primarer      Krebs      der 

Trachea    und    Bron- 

chien 

Lardillon, 

Thfese  de  Lyon,  1903 
Contribution   ^   I' etude 

du  Cancer  des  Pou- 


Lardillon, 
Loc.  cit. 


Lasegue, 
Arch.  gen.  Paris,  1877, 
I,  pp.  476-482 


Lebert, 

Compt.  rend.  See.  de 
Biol.  1849-1850,  I, 
141-150 


LeCount,  E.  R. 

Trans.  Chicago  Path. 

Soc.  Vol.   IV,    1899- 

1901,  p.  67 
Primary   Carcinoma    of 

the  Lung 


Leech,  D.  J. 

Manchester  Medical 
Chronicle,  XVI,  1892, 
p.  178 


M 


M 


M 


M 


M 


40 


66 


60 


78 


50 


Not 
stated 


53 


LUNG    IN- 
VOLVED 


Both 


R 


CLINICAL    SYMPTOMS 


After  5  months  painful  tumor  in  right 
testicle.     Duration  of  disease  9  months 

For  a  year  ssonptoms  suggesting 
bronchial  obstruction  —  dyspnoea,  etc. 
but  cause  of  the  stenosis  could  not  be 
determined.  Frequent  attacks  of  suf- 
focation in  one  of  which  death  ensued 


No  heredity.  Enters  hospital  on 
account  of  rheumatism.  Never 
coughed.  No  symptoms  pointing  to 
heart  or  lungs.  Examination  of  chest 
negative.  Later  some  pain  in  right 
chest  and  cough;  sudden  profuse 
hsemoptysis.  Repeated  hsemoptyses 
thereafter.  Gradually  increasing  dul- 
ness  over  entire  right  chest.  Dimin- 
ished voice  and  breathing.  Bloody 
serum  in  right  pleura.  Left  lung 
normal.  Finally  pneumonia  of  right 
base 

No  heredity.  Sense  of  oppression  in 
chest,  cough,  rapid  loss  of  weight  and 
strength.  Increasing  dulness  over  entire 
posterior  aspect  of  left  lung.  Dimin- 
ished respiration;  puncture  negative; 
blood  normal 


Pain,  flatness,  absence  of  voice  and 
breathing  over  lower  part  left  chest. 
Dyspnoea;  left  thorax  increased  in  size 


Clinically  merely  general  symptoms 
of  asthma 


Cough,  pain  in  chest,  dyspnoea,  ema- 
ciation. Bronchial  breathing  with  flat 
percussion  over  upper  left  chest.  Rales 
on  both  lungs.  Clinical  diagnosis:  tu- 
berculosis.    Duration  about  2  years 


Always  healthy.  More  or  less 
cough,  oppression  in  chest,  and  weak- 
ness, nevertheless  continued  to  work 
for   one  year.     After   that  cedoema  of 


CARCINOMA 


171 


No  details 


No  tubercle 
bacilli  or 
tumor 
elements 


Scant,  mu- 
copuru- 
lent, no 
tubercle 
bacilli 


Abundant, 
mucous, 
no  blood 


No  details 


Bloody, 

gelati- 
nous, no 
tubercle 
bacilli 


Bloody,  no 
tubercle 
bacilli, 
no  can- 


AUTOPSY  NOTES 


METASTASES 


almost  perforating  it 


Medullary  tumor  at  bifur- 
cation following  along  bron- 
chial ramifications 


Right  diaphragmatic 
pleurisy.  Entire  lower  lobe 
transformed  into  solid  tu- 
mor. Tumor  of  right  main 
bronchus,  penetrating  wall 
and  obstructing  bronchus  of 
right  upper  lobe 


Neoplasm  at  division  of 
main  left  bronchus  obstruct 
ing  both  branches.  Nodules 
bronchial  walls  and  in 
lung  tissue  around  bronchi. 
Bronchiectatic  cavities  and 
patches  of  gangrene.  Left 
lung  collapsed  and  atelecta- 
tic —  looks  like  Roquefort 
cheese 

Large  white  tumor  in- 
volving root  of  left  lung  and 
posterior  mediastinum,  com 
pressing  aorta  and  trachea; 
(Esophagus  and  left  vagus 
adherent  to  it 

Nodules  in  both  lungs 
suppurating  and  forming 
abscesses.  Lymphatics 
throughout  lungs  enlarged, 
forming  visible  network  of 
white  strands 

Nodules  of  various  sizes 
in  both  lungs;    diffuse  con 
solidation  of  upper  f  of  left 
lobe;   cavities  throughout 
lung 


Right  pleura  thickened 
and  adherent;  lung  pressed 
upward    and    backward. 
Large  cavity  in  middle  and 


None 


None 


Lymph 
nodes  at  left 
hilus 


No  details 


Bronchial 
glands 


None 


Left  lung, 
bronchial 
glands, 
glands 


MICROSCOPE 


Small  poly- 
hedral cells, 
more  rarely 
cylindrical 
cells 


Alveolar 
structure ; 
polymorph- 
ous cells  often 
fusiform. 
Mucoid  glob- 
ules in  some 
of  the  cells 


Alveolar 
structure ; 
polymor- 
phous cells, 
some  con- 
taining vac- 
uoles with 
colloid  degen- 
eration 


Not  given 


No  details 


Alveolar 
structure 
with  epithe 
lial  cells; 
much    degen- 
eration. 
Channels  like 
veins  filled 
with  epithe- 
lial cells 

Scirrhous 
cancerous 
structure. 
Cuboid  and 


Author  traces  ori- 
gin to  bronchial  mu- 
cous glands 


Probable  origin 
bronchial  mucous 
glands 


Cancer  was  sus- 
pected during  life  but 
the  nephritis  masked 
the  diagnosis.     Clear 


172 


TABLE  I 


172 


173 


174 


175 


176 


177 


Case  of  Cancer  of  the 
Lung 


Lehmkuhl, 

..  Diss.   Kiel,   1893 

tjber    primaren    Krebs 

der  Lunge  mit  Meta- 

stasen 


Leloib, 

Bull.    Soc.    Anat.    de 
Paris,  1879,  LVI,  719 
721 


Leopold,  Max, 

Diss.   Leipzig,  1900 

Klinischer  Verlauf  und 
Diagnostik  des  pri- 
maren Lungenkrebses 


Log.  git. 


Leopold, 
Loc.  cit. 


1903, 


Lepine,  J. 

Lyons     Med. 

Vol.  100,  p.  18 
Cancer  primitif  du  Pou 

mon  a  Globes  comes 


M 


M 


M 


M 


M 


M 


40 


39 


54 


54 


39 


60 


LUNG    IN- 
VOLVED 


R 


CLINICAL    SYMPTOMS 


legs,  puflBness  of  eyelids,  increasing 
weakness  and  dyspnoea.  Dulness 
lower  part  right  lung  with  diminished 
vocal  fremitus.  Slight  fever.  Clubbed 
fingers.  Nephritis.  27  ounces  clear 
serum  aspirated,  but  dulness  not  di- 
minished. Duration  of  disease  about 
year  and  half 

All  symptoms  mainly  cerebral  — 
headache,  delirium,  insomnia,  paralysis 
right  arm  and  leg.  Nothing  abnormal 
about  chest  except  some  impairment 
of  respiratory  motion  on  right  side. 
Clinical  diagnosis:  hsemorrhagic  pachy- 
meningitis. Death  while  patient  was 
being  prepared  for  operation 


Cachexia,  pain,  rales  over  left  apex. 
Nodules  in  right  cervical  and  inguinal 
region 


Increasing  cough  and  general  debility; 
some  pain;  dyspnoea.  Heart  disloca- 
ted to  right.  Dulness  over  both  apices; 
bloody  serum  in  both  pleurae.  Dura- 
tion 9-10  months.  Clinical  diagnosis: 
phthisis 


Cough  for  years.  Flatness  and 
absence  of  voice  and  breathing  over 
all  of  right  chest.  Heart  dislocated 
to  left.  Dyspnoea.  Bloody  serum  in 
right  pleura.  Later  hard  nodules  in 
skin  various  parts  of  the  body;  one 
of  these  nodules  removed  showed  can- 
cerous structure 


Pain  in  right  chest;  dyspnoea;  pro- 
fuse expectoration.  Hoarseness;  paral- 
ysis of  left  vocal  cord.  Flatness  be- 
tween 1st  and  2d  ribs  extending  to 
both  mammillary  lines.  Diffuse  bron- 
chitis. Later  bulging  of  entire  left 
chest.  Atelectases  of  left  apex  with 
amphoric  breathing.  CEdoema  of  legs. 
No  fever 

Year  before  entering  hospital  severe 
contusions  of  left  chest.  Shortly 
before  admission  severe  pain  sud- 
denly in  place  of  contusion.  Dulness, 
increased   vocal    fremitus,  absence   of 


CARCINOMA 


173 


SPUTUM 

AUTOPSY    NOTES 

METASTASES 

MICHOSCOPE 

EEMAEKS 

cer  cells 

outer  part  of  right  lung  with 

below  dia- 

polymor- 

serum  spoke   against 

prolongations  to   apex    and 

phragm. 

phous  cells. 

malignancy.     It  is  re- 

base.    Remainder    of    lung 

Uver,  kid- 

Origin from 

markable   that   there 

infiltrated  with  white    new 

ney,  left  su- 

alveoli 

were  no  physical  signs 

growth 

prarenal 

of  so  large  a  cavity 

None 

Tumor  size  of  a  cherry  in 

Cerebrum, 

Cylindrical 

Origin  bronchial 

right  lung 

cerebellum, 
right  supra- 
renal and 
kidneys 

epithelial 
cells  arranged 
according  to 
glandular 
type;   cells 
secrete  mu- 
cous.    Same 
structure  in 
cerebral 
metastases 

mucous  glands 

No  details 

Serous    effusion     in    left 

Both 

"True  car- 

pleura.    Tiimor  at  apex  of 

pleurae,  _ 

cinoma" 

left  lung 

mediasti- 
num, cervi- 
cal and  in- 
guinal 
lymph  nodes 

Greenish, 

Carcinoma  of  left  lung 

Right  lower 

no  tuber- 

lobe, both 

cle  bacilli 

pleurae,  ret- 
roperitoneal 
lymph 
nodes. 
Bronchial 
and  medias- 
tinal glands 
not  involved 

Mucopuru- 

Carcinoma of  right  upper 

Skin,  left 

lent,  no 

bronchus.     Hepatization 

pleura. 

tubercle 

and    purulent   degeneration 

liver,  kid- 

bacilli 

of  right  lung 

neys,  left  su- 
prarenal, 
bronchial, 
mediastinal 
and  mesen- 
teric glands 

Profuse, 

Carcinoma  of  left 

Skull,  upper 

Not  given 

bloody 

bronchus 

lobe  left 
lung,  pleura, 
liver,  bron- 
chial, medi- 
astinal, epi- 
gastric and 
mesenteric 
lymph  nodes 

Foetid,  mu- 

At place  of  swelling  whit- 

None 

Stratified 

copuru- 

ish tumor  principally  locat- 

pavement 

lent,  con- 

ed   in  lung,  surrounded   by 

epithelium 

taining 

zone   of  gangrene.     Diffuse 

with  nests  of 

elastic 

infiltration     towards    hilus. 

horny  cells 

174 


TABLE   I 


178 


179 


180 


Leplate,  M 

Th^se  de  Paris,  1888 
(Szeyelowski) 

Cancer  primitif  du  Pou- 


Le  Sotjrd, 

Bull,  et  M6m.  de  la 

Soc.  Anat.  de  Paris, 

1899,  p.  587. 
Epith61iome       mucoide 

primitif  du  Poumon 


LUNG    IN- 
VOLVED 


60 


M 


Letttlle  et  Bienvenue    F 
Bull,  et  Mem.  de  la 
Soc.   M6d.   des  Hop. 
de  Paris,  Vol.  XXV, 
3e  S6rie,  1908,  p.  610 

Cancer    primitif    de    la 


58 


63 


R 


clinical  symptoms 


breathing  at  base.  Later  cough;  en- 
larged lymph  nodes  below  left  clavi- 
cle and  in  both  axillae.  Exploratory 
needle  penetrates  soft  mass.  Dilated 
veins  of  left  chest  and  neck.  Fever; 
rapid  decline.  Death  two  months 
after  first  symptoms.  Clinical  diag- 
nosis: pleuro-pulmonary  cancer  with 
secondary  gangrene 

Always  well.  4  months  previous  to 
admission  fever,  emaciation,  pain  in 
chest,  cough.  Later  dyspnoea,  dys- 
phagia. Absolute  flatness  and  loss  of 
voice  and  breathing  over  right  up- 
per chest  anteriorly  and  posteriorly. 
Abundant  rales.  Death  from  as- 
phyxia.    Duration  about  5  months 


No  heredity.  Severe  pneumonia  2 
years  previous  to  admission.  For 
one  month  nervous  disturbances  in 
both  lower  limbs.  Dulness  left  apex; 
diminished  breathing;  normal  fremi- 
tus; intense  dyspnoea.  Right  lung 
bronchitis  and  emphysema.  No  other 
lesions  found  anywhere.  Distinct  ten- 
dency to  obesity.  Increasing  dyspnoea; 
physical  signs  practically  the  same. 
Death  from  suffocation  3  weeks  after 
admission 


No  heredity.  Healthy  until  Jan. 
1907;  then  loss  of  flesh,  hoarseness, 
attacks  of  dyspnoea  lasting  6  hours 
at  a  time.  Dulness  left  lung  below 
shoulder.  Tuberculosis  diagnosed. 
Shortly  thereafter  profuse  haemoptysis 


CARCINOMA 


175 


SPUTUM 

AUTOPSY   NOTES 

METASTASES 

MICROSCOPE 

REMARKS 

fibres,  pus 

Tumor  had   penetrated   in- 

and nu- 

terspace to  anterior  surface 

merous 

of  ribs 

bacteria 

Bloody 

Pleura  thickened,  forming 
solid  cap  over  right  upper 
lobe.       Whole    upper    lobe 
converted  into  tumor  which 
on  section  looks  like  Roque- 
fort cheese.     Tumor  prolif- 
erates into   bronchi,    which 
are  compressed  and  obliter- 
ated.      Broncho-pneumonia 
of    lower    lobe.      Left  lung 
normal 

Bronchial 
and  tra- 
cheal lymph 
nodes 

No  details 

Abundant, 

Obliteration  of  left  pleural 

Secondary 

Alveolar 

Probably    alveolar 

mucoid. 

cavity;     no    pleuritic    effu- 

nodules in 

structure  of 

origin 

No 

sion.     Both   lungs    studded 

spinal  cord 

lung  appar- 

special 

with  small  nodules.     On  tip 

with  in- 

ently pre- 

charac- 

of left   lung   large   whitish- 

volvement 

served;  alve- 

teristics 

yellow  hard  tumor;  no  cav- 

of some  ver- 

oles contain 

ity.      No  signs  of  tuberculo- 

tebrae 

cylindrical, 

sis.      Hilus   glands   scarcely 

cuboid,  poly- 

enlarged.     No  other  lesions 

morphous 

• 

anywhere 

epithelial 
cells   forming 
here  and 
there  ridges 
and  papillary 
proliferations 
into  alveoles. 
Epithelial 
lining  in 
single  or  mul- 
tiple layers. 
Some  alveoles 
not  filled 
with  cells 
contain  mu- 
coid fluid. 
Some  peri- 
bronchial 
lymph  nodes 
macroscop- 
ically  normal, 
are  found  on 
microscopic 
examination 
to  contain  tu- 
mor cells 

Mucoid, 

Primary  cancer  of  left 

Tracheal 

Alveolar 

Origin   from   bron- 

streaked 

main   bronchus,   infiltrating 

and  bron- 

structure; 

chial    mucous    mem- 

with 

into  lung  along  lymphatics 

chial  lymph 

polymor- 

brane 

blood 

and  into  alveoles 

nodes;  su- 

Dhous  epithe- 

and  rasp- 

prarenals 

ial  cells 

berry                                                         1                      1 

176 


T.^LE   I 


LTJNG    IN- 
VOLVED 


CLrNICAL    SYMPTOMS 


Bronche    primitive 
gauche 


181 


Lev^he, 

Thfese  de  Montpellier, 

1901 
Du  Cancer  Bronchopul- 

monaire  primitif 


M 


24 


R 


182 


Log.  cit. 


M 


52 


183 


LEV:feBB, 

Loc.  cit. 


43 


R 


with  violent  spells  of  coughing.  Mid- 
dle of  April  violent  attack  of  suffoca- 
tion with  profuse  hsemoptysis.  On 
admission  right  lung  slightly  emphy- 
sematous. Left  lung  behind  may  be 
divided  into  3  distinct  zones  —  above 
spine  of  scapula  everything  normal; 
consolidation  from  spine  to  point  of 
scapula  with  absence  of  breathing, 
extreme  vocal  fremitus,  and  consider- 
able bronchophony;  no  rales;  abso- 
lute flatness.  All  these  symptoms  end 
abruptly  at  8th  rib;  below  this  all  is 
normal.  In  front  normal  to  3d  rib; 
from  there  dulness  to  base.  A  band 
6  to  8  cm  wide  runs  from  left  axilla  to 
base  of  lung  where  there  is  loud  sonor- 
ous respiration  and  increased  vocal 
fremitus.  Diagnosis  of  cancer  of  lung 
made  3  months  before  death.  No 
dysphagia;  hardly  any  pain.  Death 
from  asphj^a.  Duration  about  5 
months 

No  heredity.  In  good  health  until 
3  weeks  before  admission  when  after 
drinking  ice-water  had  chill.  Treated 
for  congestion  of  lung.  Since  then 
cough,  emaciation,  intense  dyspnoea. 
No  fever;  dulness  some  rales  on  right 
side.  Pains  in  loins.  Clinical  diag- 
nosis: pneumonia.  Dulness  base  of 
right  chest;  cedcema  face,  right  arm, 
and  chest.  No  other  signs  on  lungs. 
Aspiration  negative.  Duration  IJ 
months 

No  heredity.  Admitted  to  hospital 
for  taenia.  Slight  cough;  dulness  left 
base  with  diminished  fremitus  and 
breathing.  No  pain;  no  dyspnoea. 
Later  increasing  dulness;  some  dysp- 
noea; heart  displaced  to  right.  1500 
c.c.  clear  serum  aspirated  but  dulness 
persists;  dysphagia.  Jaundice;  in- 
creasing loss  of  strength  and  flesh; 
enlargement  supraclavicular  glands. 
Clinical  diagnosis:  cancer  of  oesoph- 
agus 

No  heredity.  Always  well.  For 
6  months  intercostal  neuralgia  right 
chest;  4  months  ago  herpes  zoster  3d 
to  4th  interspace.  For  2  months  cough ; 
no  sputum;  pleuritic  effusion  and  1000 
c.c.  bloody  serum  aspirated.  Abscess 
at  place  of  puncture  and  persistent  fis- 
tula from  which  every  day  about  half 
goblet  foul,  sanious  fluid  is  discharged. 
Dulness  over  all  of  right  chest  with  loss 
of  fremitus.  Incision  shows  3d  and 
4th  ribs  destroyed  and  replaced  by 
neoplasm.  Lung  is  found  nodulated 
by    finger    introduced.     Diagnosis    of 


CARCINOMA 


177 


SPUTUM 

AUTOPSY    NOTES 

METASTASES 

MICROSCOPE 

KEMABKS 

jelly,  no 

tubercle 

bacilli. 

no  tumor 

elements 

Bloody;  re- 

Clear   serum  in    right 

Bronchial 

Epithelioma 

Author  places  ori- 

peated 

pleura.     Left  lung  normal. 

and  tracheal 

with  areas  of 

gin  from  alveolar  epi- 

profuse 

In  lower  and  middle  right 

lymph  nodes 

cheesy  degen- 

thelium 

haemop- 

lobe    a    soft     grayish-white 

compressing 

eration 

tyses 

tumor  surrounded   by  shell 
of  lung  tissue 

trachea. 

Mesenteric 

lymph 

nodes,  liver, 

pancreas, 

spleen 

None 

Left  pleura  much  thick- 

Bronchial, 

Somewhat 

Said    to    originate 

ened.       Nearly    whole    left 

mediastinal 

atypical    epi- 

from alveolar  epithe- 

lung  converted    into    thick 

lymph 

thelioma 

lium 

mass,  involving  diaphragm, 

nodes,  com- 

nodulated and  traversed  by 

pressing 

larger  and  smaller  cavities 

oesophagus. 
Lymph 
nodes  at 
hilus.   Liver 
and  spleen 

At  first 

Right  pleura  studded  with 

Mediastinal 

Epithelial 

scant, 

nodules;    right    upper  lobe 

lymph  nodes 

cancer 

several 

one  solid  mass  of  tumor,  pro- 

profuse 

liferating  through  incision  in 

hsemop- 

chest 

tyses 

13 


178 


TABLE   I 


184 


185 


186 


187 


L6VI,  LEOPOLD, 

Arch.    g6n.    de   Med. 
1895,  Vol.  II,  p.  346 
D'un    Cas    de    Cancer 
Broncho-pulmonaire 


LOSEH, 

Verhandl.    d.    phys. 
med.    Gesellschaft, 
Wiirzburg,  Vol. 
XXXIII,  1899,  p.  10 
Ein  Fall  von  Epitheliom 
der  Lunge  nach  Pneu- 


LOWENMETER, 

Deutsch.    med.    Wo- 
chenschr.  1888,  No.  44 


LtJBBE, 

Diss.  Kiel,   1896 
Ein  Fall  von  primarem 
Lungenkrebs 


M 


Not 


M 


M 


49 


stated 


76 


54 


LTJNG    IN- 
VOLVED 


R 


R 


CLINICAL    SYMPTOMS 


cancer  made.  Increasing  dyspnoea  and 
emaciation;  profuse  haemoptysis;  cedoe- 
ma  of  right  chest  and  lower  limbs. 
Increasing  pain.  Death.  Duration 
about  7  months 

No  heredity.  Always  healthy.  For 
6  months  cough,  pain  in  right  chest, 
night  sweats,  clubbed  fingers.  Later 
oedcema  of  entire  upper  body  with 
cyanosis  and  dilated  veins.  Dyspnoea. 
Dulness  lower  third  right  chest;  am- 
phoric breathing  upper  lobe.  Dys- 
phagia. Aspiration  clear  yellow  serum 
from  right  pleura;   no  relief 

No  clinical  history.  Not  even 
cause  of  death 


No  heredity.  Cough;  effusion  into 
right  pleura.  Consolidation  of  right 
lung.  No  evidence  of  tuberculosis. 
Rapidly  increasing  cachexia.  Clinical 
diagnosis:  malignant  disease  of  lung 


Diabetes  and  _  cough  for  years. 
Gradually  increasing  cough,  dyspnoea. 
Paralysis  of  both  recurrent  nerves.  In- 
creasing cachexia;  bronchitis.  Nothing 
distinctive  found  in  lungs 


CARCINOMA 


179 


Abundant, 
mucoid, 
no  tuber- 
cle bacilli 


No  details 


No  details 


Mucoid, 
later 
bronchial 
casts  and 
bloody, 
no  tuber- 
cle bacilli 


AUTOPSY    NOTES 


Right  main  bronchus 
completely  closed  by  tumor; 
tumor  size  of  walnut,  right 
upper  lobe,  encapsulated 
and  surrounded  by  healthy 
lung  tissue 


In  connection  with  a 
croupous  pneumonia  it  was 
found  at  autopsy  that  a  dif 
fuse  increase  of  connective 
tissue  had  taken  place  in  the 
lung  in  which  the  pneumonia 
had  occurred.  Numerous 
larger  and  smaller  white 
nodules  were  present  which 
were  taken  to  be  newly 
formed  connective  tissue 
Under  the  microscope,  to  the 
astonishment  of  all,  these 
nodules  as  well  as  the  diffuse 
infiltration  were  found  to  be 
extensive  tumor  formations 
Pleura  healthy 


Nodules  and  cancerous  in 
filtration  involving  nearly 
entire  right  lung.  Left  lung 
perfectly  normal 


Carcinoma  of  left  upper 
lobe;  perforation  of  right 
main  bronchus  and  trachea 
by  tumor.  Tumor  follows 
the  ramifications  of  finer 
bronchi  throughout  entire 
lung.  Left  auricle  and  up- 
per cava  penetrated  by  tu- 
mor; left  brachial  plexus 
and  aorta  surrounded  and 
compressed.  Bulging  of 
oesophagus  by  tumor  nodules 


METASTASES     MICROSCOPE 


Bronchial 
and  medias- 
tinal lymph 
nodes  com- 
pressing 
upper  cava 
and  brachio- 
cephalic 
veins 

Not  men- 
tioned 


Nodules 
in  dura  per- 
forated 
bones  of 
skull  with- 
out causing 
cerebral 
symptoms 
during  life 

Cervical, 
bronchial, 
and  medias- 
tinal lymph 
nodes;  peri 
cardium 
and  heart 
muscle 


Alveolar 
structure ; 
cylindrical, 
polygonal 
and  poly- 
morphous 
cells 


Subpleural 
nodules 
mostly  cylin- 
drical cells; 
distinct  alve- 
olar struc- 
ture.    Simi- 
lar nodules 
disseminated 
throughout 
entire  lung. 
Tumor  pro- 
liferation 

)ng  peri- 
bronchial fi- 
brous tissues. 
In  alveoles 
of  lung,  nests 
and  patches 
of  epithelial 
proliferation 
which,  how- 
ever, did  not 
fill  the  al- 
veoles 

Alveolar 
structure ; 
large  epithe- 
lial cells 


Alveolar 
structure; 
epithelial 
cells  often 
cyhndrical 


Origin  probably  from 
bronchial    mucous 
membrane 


Author  leaves 
question  undecided 
whether  this  was  a 
simple  endothelial  or 
epithelial  prolifera- 
tion after  pneumonic 
inflammation  or  a  real 
carcinomatous  pro- 
liferation. It  was 
probably  carcinoma, 
possibly  of  alveolar 
origin.     I.  A. 


Surface  epithelium 
of  smaller  bronchi 
designated  as  origin 


180 


TABLE   I 


NO. 

AUTHOR 

SEX 

AGE 

LUNG   IN- 
VOLVED 

CLINICAL    SYMPTOMS 

188 

LXJND,  0. 

Virchow-Hirsch   Jah- 
resb.  1879,  II,  p.  143. 
Norsk  mag.  f.  Lage- 
vid.  R.  3,  Vol.  VIII, 
p.  142 
Primar  Lungekraft 

F 

66 

R 

Nine  months  before  death  cough  and 
emaciation.  Later  general  brain  sjonp- 
tqms  which  completely  dominated  the 
clinical  picture.  Slight  dulness  and 
diminished  breathing  below  right  clavi- 
cle. Chnical  diagnosis:  tubercular 
disease  of  lung  and  brain 

189 

MacLachlan, 

London     Med.     Gaz. 
1843,  XXXII,  p.  23 

Primary  Cancerous  De- 
generation and  Ulcer- 
ation of  the  Lung 

M 

62 

R 

Dry  cough,  dyspncsa ;  cedoema  of  eye- 
lids, face,  and  arms.  No  pain;  no 
fever.  Dulness  with  absence  of  voice 
and  breathing  over  all  of  right  chest. 
Left  lung  normal.  Duration  about 
3  months 

190 

Malassez, 
Archiv.    de    Physiol. 
1876,  II,  353 

F 

47 

Both 

Extreme  dyspnoea 

191 

Mandlebatjm,  F.   S. 
Personal  communica- 
tion 

M 

59 

R 

Family  history  of  tuberculosis. 
Healthy  until  1907;  then  cough,  pain 
at  right  anterior  base,  loss  of  weight, 
dyspnoea  on  exertion.  Examination  6 
months  later;  heart  normal;  dulness 
right  infraclavicular  space,  broncho- 
vesicular  breathing;  flatness  and  dis- 
tant bronchial  breathing  at  right  base 
posteriorly.  All  other  organs  nega- 
tive. Clear  serum  aspirated  from 
right  base.  Clinical  diagnosis:  tumor 
of  right  lung.  Increasing  cachexia; 
partial  paralysis  of  right  recurrent 
laryngeal 

192 

Makchiafava, 

Rivista  clinica  di  Bo- 
logna, Serie  II,  1873, 
4,  p.  150 

Di  un  Cancro  primitivo 
del  polmone  a  cellule 
cilindriche  con  ripro- 
duzione  nel  cervello  a 
nell  osso  frontale 

M 

40 

Both 

Harassing  cough,  emaciation,  brain 
symptoms.  Clinical  diagnosis:  chronic 
tubercular  pneumonia.  Duration  of 
disease  about  8  months 

193 

Matne, 

Dublin  Hospital  Gaz. 
1857, 2.     Proceedings 
Path.     Soc.     Dublin, 
1856-7,  p.  191 

F 

45 

R 

Lancinating  pain  in  chest,  cough, 
dyspnoea,  cachexia.  Dilatation_  of  su- 
perficial veins.  Impaired  respiratory 
motion  of  right  chest.  Flatness  and 
bronchial  breathing  over  all  of  right 
chest.     Duration  15  months 

194 

McMtr>rN, 

Irish    Hospital    Gaz. 
1874,  II,  69-71 

F 

60 

L 

Dyspncea;  chronic  bronchitis.  Dul- 
ness over  entire  left  chest  with  feeble 
voice  and  breathing  sounds.  Dilata- 
tion of  superficial  veins.  Increasing 
pain.     Enlarged  glands  in  left  axilla 

195 

M£N]&  TRIER, 

M 

68 

R 

Always  well.     Debility,  loss  of  flesh, 

CARCINOIVIA 


181 


No  details 


Scant 


No  details 


Abundant, 
bloody, 
no  tuber- 
clebacilli, 
no  tumor 
elements 


No  details 


Scant,  later 
gelati- 
nous mu 
cus 


Mucous, 
later 

abundant 
hsemop- 
tyses 


No  details 


AUTOPSY  NOTES 


Right  main  bronchus  per- 
forated and  obstructed  by 
cancerous  tiimor  penetrat 
ing  into  right  upper  lobe  at 
the  hilus 


Whole  of  right  chest  filled 
with  firm  tumor  containing 
numerous  ca\aties.  Hard 
nodular  tumor  at  root  of 
right  lung  compressing  right 
main  bronchus,  upper  cava 
and  right  pulmonary  artery 

Numerous  nodules  in  both 
lungs  partly  confluent  and 
forming  larger  tumors 


Entire  lower  right  lobe 
converted  into  tumor  in  cen- 
tre of  which  is  large  cavity 
containing  necrotic  matter. 
Communication  between  tu- 
mor and  bronchus  of  large 
size,  the  tumor  growing  di- 
rectly into  lumen  of  bron- 
chus 


Both  lungs  studded  with 
tumor  nodules,  some  with 
central  breaking  down  and 
various  kinds  of  necrosis 


Large  white  tumor  _  at 
hilus  of  right  lung  involving 
nearly  all  of  right  lung,  which 
consists  of  hard  white  can- 
cer masses  interspersed  with 
bluish-gray  lung  substance. 
Bronchi  dilated 

Right  lung  normal.  Left 
lung  converted  into  a  pur- 
plish shrunken  mass  studded 
with  white  nodules;  cavity 
in  centre  of  lung.  Left  bron- 
chus compressed 


Large  tumor  in  right  up- 


METASTASES 


Lymph 
nodes  of 
hilus  and 
cerebellvun 


Bronchial 
and  medias- 
tinal lymph 
nodes 


None  out- 
side of  lung; 


None 


Frontal 
bone,  brain, 
cerebellum 


Mediastinal 
lymph 
nodes,  com- 
pressing up- 
per cava 


Axillary 
and  bron- 
chial lymph 
nodes; 
pleura, 
liver  and 
spleen 

Left  lung, 


MICBOSCOPE 


Simply 
stated:   carci- 
noma 


No  details 


Alveolar 
structure 
with  single 
layers  of  cy- 
lindrical cells 


of 


TjT)ical 
carcinoma 
squamous 
cell  type  with 
distinct  cell 
nests  and 
incomplete 
attempts  at 
formation  of 
homy  pearls 


Alveolar 
structure ; 
alveoli  lined 
with  tjTjical 
cylindrical 
cells,  but 
filled  with 
polymor- 
phous cells 


No  details 


Alveolar 


182 


TABLE   I 


196 


197 


198 


199 


ProgrSs    M6d.    1886 
436-437 
Cancer  primitif  du  Pou- 
mon 


MeRKLEN  &  GiRAED, 

Bull,  et  M6m.  de  la 
Soc.  Med.  des  Hop. 
de  Paris,  Vol.  XVIII, 
3d  S.  1901,  p.  760 
Cancer  primitif  des 
grosses   Bronches 


Mbunieb, 

Arch.   g6n.  de"  M6d. 

Vol.  I,  p.  208 
De    la    Pneumonia    du 

Vague 


MlNSSEN, 

..  Diss.  Kiel,  1900 
Uber     prim§,ren     Lun- 
genkreba 


MOIZARD, 

Bull,  de  la  Soc.  Anat 
de  Paris,  1875,  pp. 
732-3 
Cancer  des  Ganglions 
Bronchiques  et  du 
Poumon  droit;  enva- 
hissement  de  la  veine 
cave  superieure;  Pleu 
resie 


M 


M 


M 


M 


45 


70 


43 


63 


LUNG    IN- 
VOLVED 


R 


R 


R 


R 


CLINICAL    SYMPTOMS 


pain  in  right  chest.  Persistent  diar- 
rhcea,  cedcema  of  upper  extremities  and 
face.  Dry  cough.  Dulness  over  right 
apex.  Clinical  diagnosis:  some  ob- 
scure visceral  cancer  with  probable 
metastases  in  lungs.  Sudden  death. 
Duration  about  4  months 


Mother  died  of  cancer.  Perfect 
health  until  August,  1900.  First 
symptom:  difficulty  in  breathing  both 
when  resting  or  exercising.  After  a 
cold,  violent  cough  and  severe  attacks 
of  suffocation.  Hoarseness,  dysphagia. 
Increasing  dyspnoea;  almost  complete 
aphonia.  Dulness  over  nearly  entire 
right  lung.  Liver  pushed  downward. 
No  pleuritic  effusion.  Total  absence 
of  breathing  over  right  apex;  lower 
down  intense  bronchial  respiration  with 
crackling  rales  at  base.  Diagnosis  of 
broncho-pneumonic  cancer  was  made 
during  l^e.  Death  in  an  attack  of 
suffocation.     Duration  about  7  months 


Gout  and  bronchitis  for  years. 
Later  dyspnoea,  increasing  debility, 
loss  of  flesh,  and  severe  cough.  No 
fever.  Pleuro-pneumonia  at  right  base 
a  few  days  before  death 


Always  well  until  influenza  with 
pain  m  right  chest,  cough,  and  expec- 
toration. Since  then  increasing  dysp- 
ncea  and  debility.  Dulness  over  right 
apex;  bronchial  and  amphoric  breath- 
ing. Stridorous  respiration  and  cyano- 
sis. No  fever.  Sudden  death  from 
haemoptysis.  Duration  of  disease 
about  10  months.  Clinical  diagnosis: 
emphysema  and  pulmonary  tubercu- 
losis 

Cough;  swelling  of  extremities  and 
face.  Right  external  jugular  dilated, 
not  pulsating;  right  radial  artery 
weaker  than  left.  Heart  normal. 
Dulness  over  lower  §  of  right  lung 
posteriorly  with  diminished  voice  and 
breathing.  Superficial  veins  dilated. 
Fluid  in  right  chest.  Diagnosis:  pleu- 
ritic exudate  due  to  mediastinal  tumor 
at  root  of  lung  with  compression  or 
thrombosis  of  superior  vena  cava 


CARCINOMA 


183 


AUTOPSY    NOTES 


METASTASES 


MICROSCOPE 


per  lobe  proliferating  into 
spinal  canal.  Right  bron- 
chus and  upper  cava  com- 
pressed; both  vagi  envel- 
oped in  tumor 


both 

pleurae, 

regionary 

lymph 

nodes,  liver, 

spleen,  both 

suprarenals 


Mucopioru- 
lent, 
streaked 
with 
blood 


No  details 


Bloody, 
no  tuber- 
cle bacilli 


Trachea  adherent  to 
oesophagus;  both  surrounded 
by  enlarged  lymph  nodes. 
Primary  tumor  in  right 
main  bronchus;  lumen  al- 
most entirely  obstructed  by 
soft,  polypoid  growth  with 
pedicle  at  bifurcation.  PrO' 
fuse   degeneration   of   sur- 
rounding mucous  mem- 
brane, thickened,  white,  and 
studded  with  bluish  nodules 
Left  bronchus  and  lung  nor- 
mal.  Right  pleura  adherent 
On  section  bronchi  filled 
with  ichorous  fluid.     Lung 
tissue  studded  with  numer- 
ous white  cancer  nodules 

Mass  of  neoplasm  at  right 
hilua  infiltrating  and  ob- 
structing main  lower  bron- 
chus. Entire  lobe  con- 
verted into  cheesy,  friable 
mass  containing  small  cav- 
ities filled  with  pus  and  sur- 
rounded by  necrotic  tissue 
Pneumonic  hepatization  at 
the  periphery.  Whole  looks 
"like  sponge  filled  with 
pus."  Right  vagus  merged 
into  neoplasm 

Necrotic  carcinoma  of 
right  bronchus  perforating 
pulmonary  artery;  bronchi- 
ectatic  cavities 


No  metas- 
tases   any- 
where 
throughout 
entire   body 


No  details 


structure 
containing 
cylindrical 
and  poly- 
morphous 
cells  and  mu- 
coid degen- 
eration 

Large  bron- 
chial  vegeta 
tions,   fibrous 
stroma,   mU' 
cous  in  some 
places ;    large 
alveoles    and 
ramifying 
anastomosing 
cells,    cuboid, 
cylindrical, 
and  polyhe- 
dral.    Struc- 
ture of  pul- 
monary  nod- 
ules about 
the  same 


Cylindrical 
cells 


Origin  from  bron- 
chial epithelium 


Dark, 

clotted 
blood 


1000  c.c.  of  clear  serum  in 
right  pleura.  At  root  of 
right  lung  a  whitish  medul- 
lary mass  surrounding  but 
not  compressing  right  bron- 
chus and  extending  into  the 
superior  vena  cava,  ob- 
structing its  lumen.  _  Siini- 
lar  medullary  tumor  in  mid- 
dle lobe.  Cerebral  ventri- 
cles distended  with  pus 


Left  pleura, 
bronchial 
and  retro- 
peritoneal 
lymph 
nodes;  pan 
creas,  spleen 
and  kidneys 


None  men- 
tioned 


Alveolar 
structure, 
glandular 
cells  sur- 
rounding lu- 
men and    se- 
creting mu- 
cus 


Not  given 


Origin  from  bron- 
chial mucous  glands 


184 


TABLE  I 


200 


201 


202 


203 


204 


205 


Moore, 

London     Path.     Soc. 

XXXII,  p.  32 
Cancer  of  Right  Lung 

with     Embolism 

Middle    Cerebral 


MOBELLI, 

Deutsch.  Med.  Woch 
1907,  May  16,  p.  805 
Ein  Fall  von  primiirem 
Lungenkrebs 


MORIGGIA, 

Rivista  Clin,  di  Bolo- 
gna,   1873,     Serie  2, 
III,  5,  p.  150 
(Quoted  after  Meissner) 


MxJLLER,      HeINRICH, 

Diss.  Freiburg,  1904 
Zwei     Falle    von     pri- 
marem    Lungencarci- 
nom 


Loc.  CIT. 


MiJ'SER, 

Mitteilungen  aus  den 


M 


M 


M 


56 


28 


40 


68 


62 


53 


LUNG   IN- 
VOLVED 


R 


Both 


Both 


R 


CLINICAL    SYMPTOMS 


Definite  symptoms  of  pressure  on 
right  bronchus;  enlarged  and  hard 
cervical  lymph  nodes.  Aspiration 
yields  bloody  fluid.  Diagnosed  from 
this  during  life.  Shortly  before  death 
aphasia  and  right  hemiplegia 


No  heredity;  always  healthy.  After 
cold  with  fever  and  cough,  increasing 
loss  of  flesh  and  strength.  Chill, 
severe  pain  in  right  chest,  dyspncea. 
Consolidation  at  right  base  with  some 
pleural  effusion.  Endocarditis;  dis- 
location of  heart  to  right.  Duration 
about  7  months 


Headache  and  increasing  spasmodic 
cough.  Nausea,  depression,  emacia- 
tion. After  3  months  neuralgic  pain 
in  lumbar  and  hip  regions.  On  ad- 
mission to  hospital  signs  of  a  chronic 
tubercular  pneumonia.  After  4  weeks 
delirium  and  intense  thirst.  Clinical 
diagnosis:  tubercular  meningitis. 
Death  after  2  months 


For  some  months  considerable  ema- 
ciation, pain  in  right  leg,  foot,  and  back. 
Lungs,  with  the  exception^  of  slight 
emphysema,  normal.  Clinical  diag- 
nosis: sciatica,  lumbago,  and  arterio- 
sclerosis. Some  time  later  hard  gland 
above  right  clavicle.  Still  later,  high 
fever,  dulness,  and  bronchial  breathing 
at  right  base.  Sudden  coUapse.  With 
appearance  of  gland,  tumor  of  lung 
was  suspected.  Duration  about  5 
months 

Enters  hospital  for  psychiatric  dis- 
turbance. Lungs  normal  at  this  time. 
Later  increasing  emaciation;  rales  at 
both  bases.  Tumor  on  left  chest  ad- 
herent to  rib;  glands  in  left  axilla. 
Death  in  marasmus;  duration  of  dis- 
ease about  3  months 


General   malaise,   dyspnoea,    cough, 
fever  with  chilliness,   loss  of  weight, 


CARCINOMA 


185 


No  details 


Bloody, 

shows 
diplococci 


No  details 


No  details 


No  details 


On  surface  of  right  lung 
hard  white  new  growth  in 
patches,  penetrating  into 
lung  and  continuous  with 
similar  dense  tissue  spread- 
ing into  lung  from  root  and 
pressing  on  main  bronchus 


Both  lungs  studded  with 
small  white  nodules  corre- 
sponding to  blood  vessels, 
and  connective  tissue 
strands  which  macroscop- 
ically  suggested  fibrous  re- 
sults of  pneumonic  processes. 
Nothing  pointing  to  tumor 


AUTOPSY  NOTES 


METASTASES 


Mediasti- 
nal, bron- 
chial, and 
cervical 
lymph 
nodes 


Absolutely 
no  others 


Pleura,  heart,  pericardium 
normal.  In  lungs  numerous 
larger  and  smaller  nodules 
confluent  and  degenerated; 
small  cavities  in  centre.  In^ 
ner  surface  left  frontal  bone 
a  soft  whitish  prominence 
Meninges  healthy.  Numer- 
ous small  nodules  through- 
out brain 

Large  tumor  with  soft- 
ened and  necrotic  centre 
in  right  upper  lobe.  Right 
main  bronchus  infiltrated 
and  obstructed  by  tumor. 
Upper  lobes  both  lungs 
studded  with  small  nodules, 
Some  tuberculosis 


Scant,    mu- 
copuru- 


No  others 
mentioned 


Bronchial 
lymph 
nodes,  ribs, 
kidneys,  and 
adrenals 


MICROSCOPE 


Bands  of 
fibrous  tissue 
with  alveoli 
containing 
epithelium,  in 
some  parts 
distinctly 
columnar 

Nests  of  epi- 
thelial cells 
in  lymph 
spaces  of  fi- 
brous tissue 
and  adven- 
titia  of  blood 
vessels,  also 
epithelial 
clusters  fill- 
ing alveoles, 
in  the  alveo- 
lar septa  and 
around  blood 
vessels  and 
smallest 
bronchi. 
Cells  re- 
semble glan- 
dular cells 

Alveolar 
structure 
lined  with  cy- 
lindrical cells 


No  details 


Interesting  features 
of  this  case  are  the 
youth  of  the  patient 
involvement  of  both 
lungs  and  the  fact 
that  the  diagnosis 
could  only  be  made 
with  the  aid  of  the 
microscope 


Origin    bronchial 
mucous    glands 


Large  tumor  in  left  lung  Only  in 
extending  to  pleura;  no  con- brain 
nection  with  bronchus.  Tu- 
mor penetrates  chest  wall 
and  extends  under  pectora- 
lis.  Gangrene  of  right  lower 
lobe.  At  autopsy  tumor  is 
diagnosed  as  osteoma  of  rib 


Large   tumor  left    upper 
lobe  containing  cavity.    Af 


Bronchial 
lymph 


Typical 
carcinoma- 
tous alveolar 
structure ; 
polygonal 
epithelium 


No  details 


Author  designates 
alveoli  as  origin  of 
tumor 


186 


TABLE  I 


206 


207 


208 


209 


210 


Hamburgischen 
Staats-Kranken- 
Anstalten,  Vol.  VIII, 

..  Heft  5,  1908 

tjber  den  prim^ren 
Krebs  der  Lungen 
und  Bronchien 


Log.  cit. 


LOC.   CIT. 


LOC.    CIT. 


MtJSER, 

Loc.  cit. 


Log.  cit. 


M 


M 


M 


M 


51 


58 


66 


31 


57 


LUNG    IN- 
VOLVED 


R 


R 


R 


R 


R 


clinical  symptoms 


severe  headaches.  Choked  discs;  vari- 
ous cerebral  symptoms.  Small  area 
of  dulness  left  upper  lobe  in  front; 
otherwise  both  lungs  normal.  X-ray 
shows  spherical  shadow  extending 
from  left  hilus.  Duration  about  18 
months.  Clinical  diagnosis:  tumor 
of  left  upper  lobe  with  metastases  in 
cerebellum. 

Note.  —  Case  II  of  this  author  is 
not  included  as  there  is  no  autopsy 
and  it  is  not  certain  whether  tumor 
is  primary  in  the  lung 


Increasing  dyspnoea,  pressure,  pain. 
Later  enlarged  supraclavicular  glands. 
Manubrium  oedoematous  and  exceed- 
ingly tender  to  touch.  Right  lung 
from  2d  rib  down  complete  flatness 
and  diminished  respiration.  X-rays 
show  large  shadow  to  right  of  sternum. 
Duration  of  disease  about  3  years 

Cough,  pain,  loss  of  weight  and 
strength.  Various  paralytic  symp- 
toms. Over  middle  lobe  flatness  and 
diminished  respiration.  Secondary  tu- 
mor in  liver.  Diagnosis  made  during 
Ufe.     Duration  about  3  months 


After  influenza  severe  cough 
and  bloody  sputum.  Rapid  mental  and 
physical  decline.  Later  vertigo  and 
paralysis.  Qildoema  of  both  lungs; 
clubbed  fingers.  Flatness  right  lower 
lobe;  diminished  voice  and  breathing 
sounds.  On  exploratory  thoracotomy: 
a  cavity  filled  with  bloody  pus  and 
containing  tumor  particles  consisting 
of  polygonal  and  cuboid  cells.  At 
first  some  improvement;  then  rapid 
decline  and  death.  Duration  about 
2  years 

Two  years  before  admission  pain  in 
right  chest ;  for  three  months  loss  of 
weight,  slight  fever,  cyanosis,  dysp- 
noea, cough.  Swollen  lymph  nodes 
in  right  axilla.  Flatness  right  chest 
below  4th  rib;  diminished  respiration 
in  front;  bronchial  and  amphoric 
breathing  behind.  Exploratory  punc- 
ture shows  characteristic  granular 
cells  from  which  diagnosis  of  tumor  of 
right  lung  is  made 

Pain,  loss  of  weight  and  strength. 
Diminished  respiration  and  slight  area 
of  flatness    on    right    chest  about  2d 


CARCINOMA 


187 


lent, 
pathog- 
nomonic 
granular 
cells 


Sputum 
contained 
charac- 
teristic 
cells 

At  times 
bloody; 
charac- 
teristic 
granular 
cells 


Greenish, 
mucoid, 
fat  drop- 
lets 


ferent    bronchus   infiltrated 
with  tumor  and  ulcerated 


Bloody, 
raspberry 
jelly, 
profuse 
hgemop- 
tysis 


Bloody, 
charac- 
teristic 
granular 
cells 


None 


AUTOPSY  NOTES 


METASTASES 


Large  carcinoma  of  right 
middle  lobe  extending  into 
lower  lobe 


Bloody  serum  in  right 
pleura.     Large  tumor  in 
middle  and  upper  right 
lobes.   Carcinomatous  infil- 
tration afferent  bronchus 


Carcinoma  of  right  lower 
bronchus,  tumor  cavity  al- 
most completely  filling  right 
lower  lobe 


Large   tumor   near   right 
hilus  starting  from  bronchus 


nodes  and 
cerebellum 


Hilus  and 
supraclavic- 
ular glands 


Bronchial 
and    epigas- 
tric lymph 
nodes,  liver, 
5th  rib,  in 
number  of 
vertebrge. 
Compres- 
sion of  spi- 
nal cord 

Right  lung 
and  cerebel- 
lum 


Liver  and 

lymph 

nodes 


MICROSCOPE 


No  details 


No  details 


No  details 


Carcinoma 


No  details 


Operation  :  Tumor 
of  right  lung  contain- 
ing cavity.  As  much 
of  tumor  as  possible 
removed.  Recovered 
and  has  remained  well 
for  a  year 


188 


TABLE  I 


NO.  AUTHOR 


LUNG    IN- 
VOLVED 


211 


212 


213 


214 


215 


Log.  cit. 


Log.  cit. 


Loo.  CIT. 


Log.  CIT. 


Log.  CIT. 


M 


M 


M 


M 


M 


59 


72 


59 


65 


44 


216 


Log.  CIT. 


M 


58 


217 


Log.  GIT. 


M 


68 


R 


218 


Log.  git. 


M 


74 


CLINICAL    SYMPTOMS 


to  3d  rib.  Otherwise  both  lungs  nor- 
mal. No  cough.  Death  from  sudden 
collapse.     Duration  about  2  months 


Emphysema  for  years.  Recently 
loss  of  weight  and  strength;  cyanosis; 
dulness  over  left  base  with  diminished 
respiration.     Effusion  in  right  pleura 

Dyspncsa,  cough,  pain,  rapid  loss  of 
weight.  Left  chest  flattened,  impaired 
respiratory  motion ;  flatness,  no  breath- 
ing sounds.  After  aspiration  1050  c.c. 
brown  serum,  flatness  remains 


Sudden  cough,  expectoration,  slight 
pain.  Loss  of  flesh  and  strength. 
Dulness  over  left  upper  lobe  with 
feeble  breathing  sounds  and  impaired 
respiratory  motion.  Duration  about 
10  months 

Cough,  rapid  emaciation.  Dulness 
over  entire  left  upper  lobe;  diminished 
breathing,  bronchial  toward  hilus. 
Duration  about  2  months 


Cough,  expectoration,  increasing 
loss  of  strength  and  weight.  Flatness 
over  all  of  left  lobe;  impaired  respira- 
tory motion;  loss  of  breathing  and 
voice  sounds 


Cough,  expectoration,  loss  of  weight 
and  strength.  Dulness  over  left  upper 
lobe  and  sternum;  a  few  large  rales. 
Greatly  diminished  respiration.  Dura- 
tion about  year  and  half 


Cough,  expectoration,  loss  of  weight. 
Retraction  right  upper  chest;  flatness 
right  upper  lobe  with  diminished 
breathing  sounds;  no  vocal  fremitus. 
Emphysema  and  bronchitis  in  remain- 
der of  lungs 


Cough,  pain,  loss  of  weight.  Dul- 
ness over  left  lobe  posteriorly  with 
diminished  voice  and  breathing 


CARCINOMA 


189 


AUTOPSY    NOTES 


METASTASES 


MICHOSCOPE 


No  details 


Granular 

fatty  cells 


Mucoid, 
bloody; 
no  as- 
sured 
granular 
cells 

No  details 


Mucoid, 
often 
bloody, 
some- 
times 
prune 
juice.  No 
tubercle 
bacilli 
but  gran- 
ular cells 

Nothing 
charac- 
teristic 


Mucoid 


Bloody 
with  char- 
acteristic 


Carcinoma  left  lower  lobe 
starting  from  main  bronchus 


Left  upper  and  lower  bron- 
chi infiltrated  with  tumor 
penetrating  into  lung  and 
forming  nodules 


Ulcerated  carcinoma  of 
left  main  bronchus  with  tu- 
mor containing  cavity  in  left 
upper  lobe 


Large  carcinoma  starting 
from  left  main  bronchus 


Carcinoma  from  left  main 
bronchus  involving  nearly 
whole  of  left  lower  lobe. 
Embolus  left  pulmonary  ar- 
tery; aneurysmatic  dilata- 
tion left  ventricle 


Large  carcinoma  from  left 
main  bronchus;    bronchus 
left  upper  lobe  completely 
closed  by  tumor 


Carcinoma  at  first  bifurca- 
tion right  main  bronchus,  al- 
most completely  obstructing 
right  upper  bronchus  and 
proliferating  along  bron- 
chial ramifications  through 
upper  lobe.  Bloody  serum 
in  pleura 

Carcinoma  of  left  main 
bronchus  involving  nearly 
all  of  left  lower  lobe.     Puru 


which  com- 
press recur- 
rent laryn- 
geal and 
vagus 

Liver 


Both 

pleurae, 
bronchial 
and  tra- 
cheal lymph 
nodes 

Bronchial, 
tracheal, 
and  medias- 
tinal lymph 
nodes 


Mediastinal 
lymph 
nodes  com- 
pressing re- 
current 

No  details 


Bronchial 
and  tracheal 
lymph 
nodes,  liver 
and  dura. 
Pyloric  car- 
cinoma is 
also  found 

Pericar- 
dium, heart, 
kidneys,  and 
suprarenals 


Small  carci- 
noma in 
stomach 


No  details 


No  details 


No  details 


No  details 


No  details 


No  details 


No  details 


Author     implies 
that  pyloric  carci- 
noma is  distinct  and 
independent   of   lung 
tumor.      Microscopic 
structure  unfortu- 
nately not  given 


190 


TABLE    I 


219 


220 


221 


222 


223 


224 


MtJSER, 

Loc.  cit. 


Loc.  CIT. 


MrrssELiER, 

Gaz.  M6d.  de  Paris 

1886,   159 
Cancer  primitif  du  Pou- 

mon 


M 


M 


MUSSBR,   J.   H. 

Univ.    Penna.    Med 
Bull.  Vol.    XVI,  Oct 
1903,   No.  8,  p.  289 
Primary  Cancer  of  Lung 


Loc.  CIT. 


Maun,  I. 

Deutsch.    med.    Zeit. 

XXVI,    1905,   p.   537 
Ein  Fall   von   primarer 

Krebsentwickelung  in 

den  Bronchien 


59 


67 


F       76 


M 


M 


M 


LUNG    IN- 
VOLVED 


R 


R 


49 


47 


50 


R 


Both 


CLINICAL   STMPTOMa 


Cough,  pain,  loss  of  weight.  Im- 
paired respiratory  motion.  Dulness 
and  diminished  voice  and  breathing 
over  left  lower  lobe.  Duration  about 
2  years 

Always  healthy.  Recently  cough, 
dyspnoea.  Dulness,  diminished  bron- 
chial breathing,  impaired  respiratory 
motion  over  right  upper  lobe 


No  heredity;  always  well.  Pain  in 
right  shoulder;  later  small  hard  tumor 
below  right  clavicle;  subsequently  sim- 
ilar tumor  below  left  clavicle.  Irreg- 
ular area  of  dulness  in  right  chest 
posteriorly  with  feeble  respiration. 
Paraplegia.  No  cough;  no  dyspnoea. 
Duration  about  7  months.  Diagnosis 
made  during  life  from  the  bloody  spu- 
tum, pain  and  tumors  below  clavicle 


No  heredity.  Clinical  symptoms 
those  of  pleuropneumonic  infection. 
SUght  fever,  physical  signs  of  effusion; 
aspiration  negative.  Exploration  re- 
vealed nodule  in  lung.  Marked  leu- 
cocytosis.  Cachexia  very  late.  Dura- 
tion less  than  3  months 

_  No  heredity.  Sore  throat  _  only  at 
night  and  in  recumbent  position.  In- 
digestion, dyspncea,  loss  of  flesh  and 
strength.  Moderate  cough  causes 
bringing  up  of  large  amount  of  fluid. 
Slight  pleural  friction  in  right  axillary 
region  only  physical  sign  on  lungs. 
Nothing  characteristic  in  blood.  Signs 
of  bronchitis  and  pleuritis;  rales  at 
both  bases.  Intense  dyspnoea;  in- 
creased leucocytosis.  Duration  about 
5  months 


Lues  20  years  ago.  Recently  loss 
of  weight  and  strength;  repeated 
haemorrhages.  Persistent  pain  with- 
out swelling  in  all  joints.  Near  left 
costoclavicular  articulation  a  tumor 
size  of  a  walnut,  hardly  movable, 
slightly  fluctuating.  Dulness  over 
both  supraspinous  fossse;  dulness  left 
with     diminished     respiration. 


CARCINOMA 


191 


BPUTUM 

AUTOPSY    NOTES 

METASTASES 

MICROSCOPE 

REMARKS 

fatty 

lent  exudate  in  left  pleural 

granular 

cavity 

cells 

Bloody, 

Nearly  whole  of  left  lower 

No  details 

No  details 

fatty 

lobe  converted  into  hard 

granular 

cancerous  mass.     Bloody 

cells 

fluid  in  left  pleura 

Purulent, 

Carcinoma  of  right  upper 

Bronchial 

No  details 

bloody 

bronchus;  obliteration  of 

lymph 

with 

pleura.     Bronchiectasis  and 

nodes  and 

"Fett- 

bronchopneumonic  areas  in 

liver 

korn- 

both  lower  lobes 

chen" 

Currant 

Several  larger  and  smaller 

No  others 

No  details 

jelly 

tumors  softened  in  centre  in 
upper   portion    right   lower 
lobe 

No  details 

Massive   tumor   of   right 

Left  lung, 

■ 
No  details 

A    second    case    is 

lower  lobe 

liver,  tho- 
racic lymph 
nodes 

not  included  because 
there  was  no  autopsy 
but  there  is  no  doubt 
that  it  was  a  similar 
case 

Not  bloody, 

Diffuse  yellowish  gray  in- 

Cervical, 

General  al- 

No   anatomical 

no  tuber- 

filtration uniformly  through- 

bronchial, 

veolar  ap- 

cause for  the  orthop- 

cle  bacilli 

out  both  lungs.      No  pleu- 

tracheal, 

pearance  of 

noea  and  sore  throat 

ritic  effusion 

and  retrope- 

lung re- 

could be  found.  Clin- 

ritoneal 

tained;  fre- 

ical diagnosis  was  tu- 

lymph 

quent  areas 

berculosis 

nodes 

of  necrosis. 
Flat  epithe- 
lial   cells    re- 
sembling al- 
veolar epithe- 
lium; in  older 
portion  dis- 
tinctly papil- 
lary arrange- 
ment and  cy- 
lindrical cells 

Abundant, 

Left  lung  adherent;    near 

Areas  of 

Abundant 

Practically  no  pain. 

mucopu- 

posterior border  large   cav- 

neoplasm in 

firm    stroma ; 

no    dyspnoea,    and 

rulent; 

ity;     numerous     bronchiec- 

pericardium 

alveolar 

nothing  characteris- 

no tuber- 

tatic cavities  containing  pus. 

and  left  ven- 

structure 

tic.     Only  significant 

cle  bacilli; 

Right  lung  normal.     A  mass 

tricle 

filled  with 

symptoms  initial  hae- 

repeated 

the  size  of  an  orange  at  bi- 

polymorph- 

moptysis and  rapidly 

hsemop- 

furcation  of  main  bronchus; 

ous  epithe- 

increasing cachexia 

tyses; 

similar  tumor  at  lower  end 

lial  cells; 

later 

of  trachea  toward  left.  Near 

plentiful 

192 


TABLE  I 


225 


226 


227 


NEtTMEISTEB, 

Miinch.     med.     Wo 
chenschr.  No.  36,  52, 
1905,  p.  1721 
Ein  Fall  von  primarem 
Plattenepithelkarzi- 
nom  der  Lunge,  etc 


Oberthub, 

Revue   Neurol.    Vol 
X,  Paris,  1902,  p.  485 


Oesteeich, 

Berl.  klin.  Wochen- 
schrift,    1892,  p.  104, 
Demonstration 


M 


63 


32 


62 


LUNG  IN- 
VOLVED 


R 


CLINICAL    SYMPTOMS 


Cough.  Pain  left  base.  Aspiration, 
clear  blood.  Diarrhoea.  No  fever: 
Haemoglobin  40,  leucocytes  15,000. 
Death  from  exhaustion.  Duration 
about  one  year.  First  diagnosis  was 
tuberculosis,  then  pneumonia  with 
bronchiectasis.  Only  very  late  during 
life  was  there  a  suspicion  of  malignancy 

Had  pleurisy  some  years  ago.  Weak, 
cachectic;  suffered  for  year  with  pain 
in  right  shoulder  joint.  Clinical  diag- 
nosis: pulmonary  tuberculosis  and  tu- 
berculosis of  right  shoulder  joint 


No  heredity.  At  age  of  27  both 
ovaries  removed  for  cystic  degenera- 
tion. About  middle  of  1899  she  com- 
plained of  vague  pain  along  spine,  in 
shoulder  and  chest  even  on  slightest 
effort.  Loss  of  appetite  and  flesh. 
End  of  year,  frequent  painful  attacks, 
cough,  bloody  sputum.  Diagnosis  at 
that  time  tuberculosis.  Patient  then 
commenced  to  drink  large  quantities 
alcoholic  liquors.  Increasing  dyspnoea, 
CBdcemaof  lower  extremities.  Nervous 
symptoms  now  predominate,  painful 
cramps  in  both  upper  and  lower  ex- 
tremities and  along  spine  which  pre- 
vent sleep.  Rapid  atrophy  of  muscles. 
Soon  not  only  walking  but  almost 
every  movement  becomes  impossible; 
intense  general  hypersesthesia.  Details 
of  neurological  examination  omitted. 
Continuous  dyspnoea ;  absolute  flatness 
over  whole  of  left  lung.  Total  absence 
of  breathing  except  some  amphoric 
respiration  at  hilus.  Dulness  at  base 
of  right  lung  with  friction;  harsh 
breathing  throughout  and  some  rales. 
Continuous  sweating.  Chnical  diag- 
nosis: alcoholic  polyneuritis  and  pul- 
monary tuberculosis 

Malaise  for  some  time.  Effusion 
of  clear  serum  in  right  pleura.  In- 
creasing dyspnoea,  cyanosis,  cedoema  of 
upper  body 


CARCINOMA 


193 


AUTOPSY   NOTES 


METASTASES 


MICKOSCOPE 


bloody 


No  details 


origin  of  left  main  bronchus 
a  }  cm.  whitish  yellow  mass 
destroying    the    cartilages 
and  penetrating  into  lumen 
of  bronchus 


Anatomical  diagnosis:  tu- 
berculosis of  left  lung;  bron- 
cho-pneumonia of  right;  pu- 
rulent bronchitis;  cheesy 
degeneration  of  right  supra- 
renal, tubercular  arthritis 
right  shoulder  joint 


Only  in 
right  shoul- 
der joint 


Abundant, 
mucopu- 
rulent, 
often 
streaked 
with 
blood, 
but  no 
"currant 
jelly." 
Sputum 
not  ex- 
amined 
micro- 
scopically 


No  details 


Large  quantity  yellow 
serous  fluid  in  left  pleura; 
small  quantity  in  right. 
Cancerous  pleurisy ;  cancer 
ous  lymphangitis.  Left  lung 
retracted,  atelectatic,  and  fi' 
brous  at  apex.     Whole  left 
lower  lobe  and  hilus  a  mas- 
sive cancer,  soft  in  interior 
and  fibrous  exteriorly. 
Large  and  medium  size 
bronchi    disappear    entirely 
in  tumor.     Small  secondary 
nodules  especially  near  hilus 
in  right  lung  around  bron 
chi.     Swollen  mediastinal 
lymph  nodes  envelop  base 
of  trachea  and  main  bronchi 
Pericardium    and    myocar- 
dium contain  miliary  nod- 
ules;    innumerable    miliary 
nodules  in  skin  and  muscles 
all  over  body 


Carcinoma  of  right  main 
bronchus  involving  lung 
along  bronchial  ramifica- 
tions;   some  obstruction  of 


2  secondary 
nodules  in 
uterus;  mill' 
ary  nodules 
in  both  kid- 
neys, supra- 
renals,  pan- 
creas, liver, 
retroperito- 
neal  glands 
pericardium, 
myocar- 
dium, skin, 
and  muscles 


karyokinesis. 
Origin  from 
bronchial 
mucous  mem- 
brane 


Capsule  of 
joint    showed 
no  tuberculo- 
sis but  infil- 
tration  with 
typical  can- 
croid pearls. 
In  the  lung 
innumerable 
foci  of  carci 
noma  of  can^ 
croid  type 
which  could 
not  be  differ 
entiated  from 
the  tubercu- 
lar tissue 
which  was 
everywhere 
intermingled 

Glandular 
epithelium 
with  cylindri- 
cal cells  with 
many  karyo 
kinetic  figures 


Discussion  whether 
primary    in    lung. 
Probable  origin  bron- 
chial mucous  glands. 
Microscopic  study  of 
nerves   and   muscles, 
also  mUiary   nodules, 
all  show  same  char- 
acter as  primary  tu- 
mor.    Nothing    in 
brain,  medulla  or  me- 
ninges.   Lesions  in 
nervous    system   and 
muscles  by  their  pres- 
sure cause  degenera- 
tion   of    nerve     and 
muscle     fibres     with 
pseudo-hypertrophy 
in  the  latter 


No  details 


No  details 


14 


194 


TABLE  I 


228 


229 


Otten, 

Fortschritte  auf  dem 
Gebiete  der  Roent- 
genstrahlen,  Vol.  IX. 
Heft  6,   1906,  p.  369 

Zur  Roentgen-diagno- 
stik  der  primaren 
Lungencarcinome 

Log.  cit. 


230 


231 


232 


233 


Log.  err. 


Otten, 

Loc.  cit. 


Log.  cit. 


Loc.   CIT. 


234 


235 


Log.  cit. 


Loc.   CIT. 


SEX       AGE 


M 


M 


M 


M 


M 


M 


M 


69 


67 


60 


61 


65 


66 


62 


LtTNG    IN- 
VOLVED 


R 


R 


R 


CLIiaCAIi    SYMPTOMS 


Pain  in  right  chest,  cachexia,  CEdcema 
of  right  arm;  dilated  veins  over  right 
chest  and  belly.  Dulness  and  absence 
of  breathing  over  right  upper  lobe. 
Some  dyspnoea;  no  cough 


No  heredity.  Cough  and  expectora- 
tion for  years;  otherwise  well.  Diag- 
nosis at  first,  tuberculosis.  Later  pain 
in  right  shoulder,  cough,  dyspnoea,  cya- 
nosis of  upper  body.  Enormous  dila- 
tation of  superficial  veins;  cedcema  of 
arm.  Cachexia.  Dulness  right  upper 
lobe  with  signs  of  cavity.     No  fever 

Father  died  of  carcinoma  of  stomach. 
For  4  months  pain  in  right  chest, 
cough,  expectoration;  general  debility. 
Enlarged  axillary  glands.  Dulness 
right  upper  and  middle  lobes.  Dura- 
tion of  disease  about  5  months 

Cough    and    mucoid    expectoration 

for  several  years.  Increasing  dyspnoea, 
emaciation,  and  debihty.  Enlarged 
glands  in  both  axillae.  Dulness  over 
nearly  entire  left  lung.  Some  fever. 
Death  after  about  5  months 

Mother  carcinoma  of  uterus.  Always 
well.  For  6  weeks  increasing  weakness, 
loss  of  flesh,  dyspnoea,  cough,  pain 
in  chest  and  back;  attacks  of  suffo- 
cation; some  fever.  Dulness  right 
middle  and  lower  lobes.  Impaired 
respiratory  motion.  Haemorrhagic  ef- 
fusion in  right  pleura 

No  heredity;  always  well.  For 
about  On  months  bloody  expectoration, 
loss  of  weight,  cough,  cyanosis,  dysp- 
noea; moderate  fever.  Enlarged  axillary 
and  cla\ricular  glands  on  right  side. 
Hoarseness.  Consolidation  of  right 
upper  lobe 

No  heredity.  For  .5  months  cough, 
dyspnoea,  increasing  debility,  and  loss 
of  weight.  Signs  of  consolidation  of 
right  upper  lobe  with  dry  pleurisy  in 
right  chest.  Bloody  effusion  in  left 
chest.     Paresis  of  left  recurrent 

No  heredity.  For  several  months 
increasing  weakness  and  loss  of  flesh. 


CARCINOMA 


195 


SPUTUM 

AUTOPSY  NOTES 

METASTASES 

MICROSCOPE 

EEMAEKS 

left    bronchus.       Extensive 
gangrene  of  lung;  bronchiec- 
tasis.    Compression  of  up- 
per cava,  aorta  and  oesopha- 

gus 

None 

Carcinoma  of  right  upper 
lobe.     Thrombosis     right 
subclavian  and  axillary  veins 

Glands  of 
hilus  and 
right  axilla 

No  details 

Mucopuru- 
lent 

Carcinoma  of  right  upper 
lobe  with  cavity  in  centre. 
Thrombosis  upper  cava  and 
both  internal  jugulars 

Lymph 
nodes  at 
root 

No  details 

No  details 

Carcinoma  of  right  main 
bronchus  and  infiltration  of 
upper  and  middle  lobes 

Bronchial 
lymph 
nodes  and 
liver 

No  details 

Mucoid 

Carcinoma  of  entire  left 
lung 

Liver,  hi- 
lus, and  axil- 
lary   lymph 
nodes 

No  details 

Purulent 

Carcinoma  of  large  bron- 
chus of  right  side  with  infil- 
tration of  entire  middle  lobe 

Liver,   right 
adrenal 

No  details 

Bloody 

Carcinoma  of  right  bron- 
chus infiltrating  upper  and 
middle  lobes 

Axillary 
and  clavicu- 
lar glands 

No  details 

Mucoid 

Carcinoma   of   left   main 
bronchus  infiltrating  a  large 
part   of   left  upper  lobe. 
Pneumonia   of   right    lower 
lobe 

Glands  of 
left  hilus 

No  details 

No  detaUs 

Carcinoma    of  left   main 
bronchus    infiltrating    large 

Bronchial, 
tracheal. 

No  details 

196 


TABLE  I 


236 


237 


238 


239 


240 


241 


242 


Loc.  err. 


Log.  cit. 


Loc.  CIT. 


Loc.  CIT. 


Loc.   CIT. 


Pabssleb, 

Virchows   Arch.  Vol. 
..  145,  1896,  p.  191 
Uber  das  primare  Kar- 

zinom  der  Lunge 


Loc.  CIT. 


M 


M 


M 


M 


M 


M 


49 


53 


Not 
stated 


67 


51 


73 


52 


LXTNG    IN- 
VOLVED 


R 


R 


R 


CLINICAL   SYMPTOMS 


Cough,  pain  in  left  chest,  dyspnoea, 
and  cyanosis.  Enlarged  left  axillary 
and  clavicular  glands.  Dilated  veins 
left  shoulder.  Dulness  over  left  upper 
lobe.  Absence  of  breathing  over  all 
of  left  chest.     Paralysis  left  recurrent 

No  heredity.  For  about  2  months 
cough,  expectoration;  later  dyspnoea 
and  palpitation.  Hoarseness,  cyano- 
sis, paralysis  of  left  recurrent.  Infil- 
tration of  left  upper  lobe 

No  heredity.  For  about  6  months 
increasing  debility,  loss  of  flesh, 
stomach  trouble.  During  last  few 
weeks  fever,  headaches,  dizziness. 
Cachexia,  choked  discs,  ataxia.  Small 
area  of  dulness  to  left  of  manubrium 
sterni 

No  heredity.  For  2  years  varying 
symptoms.  Dyspnoea,  cough,  some 
pain  in  chest.  No  fever.  Small  dull 
area  to  right  of  sternum  gradually 
extending  over  greater  portion  of  right 
chest 

No  heredity.  For  6  months  cough 
with  expectoration,  loss  of  strength 
and  weight,  increasing  dyspnoea.  Slight 
fever;  physical  signs  of  profuse  bron- 
chitis over  both  lungs.  Enlarged 
glands  in  right  supraclavicular  fossa 

Father  probably  died  of  cancer. 
For  3  months  pain  in  left  chest.  Cough, 
increasing  loss  of  flesh  and  strength, 
slight  fever.  Dulness  over  left  lower 
lobe.  Attempt  was  made  to  remove 
left  lower  lobe  by  operation.  Increas- 
ing cachexia;  steady  fever.  General 
carcinosis  of  left  pleura 

Well  until  6  weeks  before  death; 
then  slight  cough,  scant  sputum, 
paralysis  of  left  recurrent.  Pneumonia 
of  left  lower  lobe.  Clinical  diagnosis: 
anexxrism  or  mediastinal  tumor 


Always  well.  Little  cough,  no  pain, 
some  persistent  hoarseness.  Without 
premonition  2  sudden  and  profuse 
haemoptyses  causing  death  in  2  days 
Clinical  diagnosis:  pulmonary  phthisis 


i 


CARCINOMA 


197 


Scant,    mu- 
coid 


Purulent 


Often 
bloody, 
profuse 


Mucopuru- 
lent, 
later 
bloody 


Bloody 


Scant, 
never 
bloody 


None 


AUTOPSY    NOTES 


area  of  upper  lobe.     Sero-     axillary,  and 
sanguinolent  effusion  in  left  clavicular 
pleura  lymph 

nodes 


Carcinoma   of  left   main  Both  lower 
bronchus  lobes 


Carcinoma  of  main  bron-  Bronchial 
chus  of  left  upper  lobe  infil-  lymph 
trating  nearly  all  of  upper  nodes  and 
lobe  cerebellum 


Bronchial  carcinoma  infil-  Both  lungs 
trating  right  middle  lobe 


Carcinoma  of  right  large  Lung,  bron 
bronchus  infiltrating  middle  chial,  and 
and  part  of  upper  lobe.   Nu-  supraclavic- 
merous  bronchial  and  peri-  ular    glands 
bronchial  nodules  through 
out  other  lobes 

Left  lower  lobe  almost  en-  Pleura, 
tirely  removed;  remnant  pericar 
cancerous.  Carcinosis  of  dium,  heart, 
left  pleura ;  carcinomatous  left  kidney, 
pericarditis.  Old  tubercu-  left  adrenal 
losis  right  apex 


Ulcerated  medullary  car-     Lymph 
cinoma  of  left  main  bron-  nodes  at 
chus.     Compression  of  tra-  root  of   left 
chea;    numerous  bronchiec- lung 
tatic  cavities  in  left  upper 
lobe.     Aspiration    pneumo- 
nia of  left  lower  lobe. 
Hsemorrhagic  effusion  in  left 
chest.     Compression  of  left 
recurrent 

Carcinomatous  ulceration  Large  ves- 
of  right  main  bronchus.        sels  and 
Erosion  of  branch  of  right  nerves,  left 
pulmonary  artery.     Cancer-  auricle  and 
ous  infiltration  in  walls  of  pericardium 
large  vessels  and  nerves, 
proliferates  through  pulmo- 
nary vein  into  left   auricle 
and  into  pericardium 


METASTASES 


MICROSCOPE 


No  details 


No  details 


No  details 


No  details 


No  details 


Cylindrical 
celled  carci- 
noma 


Homy   pave- 
ment celled 
cancer 


198 


TABLE  I 


243 


244 


245 


246 


247 


248 


Log.  git. 


Loc.  CIT. 


Papinio,  Pennato, 
Riv.  Ven.  di  Scienza 
Med.  Anno  X,  Tomo 
XIX,    p.    393,    Nov. 
1893 

Carcinoma  primitive  del 
Polmone 


Parow, 

Diss.  Greifswald,  1896 
Ein  Fall  von  primarem 

LungencarcLnom 


Passow, 

Diss.     Berlin,     1893 
(After  Paessler) 

Zur    Differentialdiagno- 
se    der   Lungentumo- 
ren   insbesondere  der 
primaren  Lungen- 
krebse 

Peacock, 

London    Path.     Soc. 

IV,  1849-50 
Primary  Cancer  of  the 

Lung 


M 


M 


M 


63 


46 


12 


62 


51 


43 


LUNG    IN- 
VOLVED 


R 


R 


CLI1«CAL   SYMPTOMS 


Apoplexy  with  paresis  of  right 
facial,  _  hypoglossal,  arm,  and  leg. 
Cachexia.  Respiration  normal  but 
diffuse  dry  rales  with  some  pleuritic 
friction.  Clinical  diagnosis:  general 
paresis.     Duration  about  5  months 

No  heredity.  Syphilitic  symptoms 
for  many  years.  For  a  few  days  pain 
in  left  chest,  cough,  and  dyspnoea. 
Flatness  with  feeble  inspiration  and 
absence  of  vocal  fremitus  on  left  chest. 
Intense  dyspncea  and  cyanosis.  Aspi- 
ration: clear  serum;  sudden  death  at 
end  of  aspiration.  Clinical  diagnosis: 
pleurisy  and  lues 

111  6  months  before  admission  with 
pain  in  right  chest,  sweats,  attacks  of 
cough  without  expectoration;  prostra- 
tion. On  admission  pale,  emaciated 
child,  right  chest  larger  than  left; 
impaired  respiratory  motion  of  right 
side.  Upper  right  intercostal  spaces 
obliterated.  Enlarged  gland  in  right 
axilla.  Absolute  dulness  over  whole 
anterior  of  right  chest,  also  laterally 
and  posteriorly  except  for  a  small 
space  along  spine  at  apex  which  gave 
a  little  resonance.  Heart  displaced 
toward  left;  nothing  essential  in  left 
lung.  No  fever.  150  c.c.  blood  from 
pleural  cavity.  Second  exploratory 
puncture  only  a  few  drops  of  blood. 
Dyspncea;  cyanosis.  Death  after  3 
weeks    in    hospital 

No  heredity.  Indefinite  symptoms 
for  some  time.  Later  dyspnoea,  ca- 
chexia, dysphagia.  Tumor  in  right 
supraclavicular  region 


No  clinical  details 


Pain  in  chest,  difScult  breathing, 
cough,  cachexia.  Complete  dulness 
over  upper  left  chest,  feeble  inspiration 
and  prolonged  expiration  suggesting 
compression  of  bronchus.  Later  in- 
tense dyspnoea,  cyanosis,  swelling  of 
face,  neck,  chest,  and  arms.  Swelling 
of  glands  on  each  side  of  neck.  Entire 
left  lung  impervious  to  air.  Duration 
of  illness  about  10  weeks 


CARCINOMA 


199 


AUTOPSY    NOTES 


METASTASES 


MICROSCOPE 


No  details 


No  details 


None 


No  details 


No  details 


None 


Carcinoma  of  main  bron- 
chus of  left  lower  lobe 


Almost  complete  com- 
pression of  left  lung;   sub- 
pleural   carcinoma  of  left 
upper  lobe 


Nearly  entire  right  chest 
occupied  by  spheroid  mass, 
soft  and  semi-fluctuating. 
Upper  lobe  of  lung  pressed 
upward  and  backward.  Two 
lower  lobes  replaced  by  neo- 
plasm. All  other  organs 
normal 


Carcinoma  right  main 
bronchus  and  beginning  of 
left.     Bronchiectases    and 
atelectases  right  upper  lobe. 
Large  nodiile  compresses 
CESophagus 

Carcinoma  involving 
bronchi  and  lung  and  pene 
trating  anterior  wall  of  chest 


Tumor  right  upper  ster- 
num and  external  end  left 
clavicle  in  connection  with 
masses  of  carcinoma  imbed- 
ded in  upper  part  left  lung 
and  extending  along  bron- 
chus to  bifurcation  and 
down  posterior  mediasti- 
num. In  lung,  divisions  of 
bronchus  almost  obliterated; 
branches  of  pulmonary  ar- 


Lower  lobe 
right  lung, 
liver,  and 
many  in 
brain 


Miliary 
cancer  nod- 
ules in 
pleura  and 
middle  and 
upper  right 
lobes.     No 
other  meta- 
stases 

None  ex- 
cept gland 
in  right 
axilla 


Cylindrical 
celled  carci- 
noma 


Cylindrical 
celled  carci- 
noma 


Cervical 
and  supra- 
clavicvQar 
lymph 
nodes 


Medias- 
tinum and 
supraclavic- 
ular lymph 
nodes 


No  further 
details 


Probably 
carcinoma 


Cylindrical 
and  polymor- 
phous epithe- 
lial cells 


Cylindrical 
cells 


Author  mentions  as 
origin  surface  epithe- 
lium of  bronchi 


No  details 


200 


TABLE  I 


249 


Pearson,  Chas.  L. 

Charlotte  Med.  Jour. 

XV,  1899,  p.  633     • 
Case     of     Encephaloid 

Carcinoma    of    Lung 

with  Tuberculosis 


250 


Pbnsttti,  v. 

Lavori  dei  Cong,  di 
Med.  Intern.  Nono 
Cong.  Ten.  in  Torino, 
neir  Ottobre  1898 
(Roma,  1899),  p.  338 


251 


262 


Pbpbbb, 

Centralbl.  f.  Path 
Anat.  Vol.  XV,  1904, 
p.  948 


Pbbitz, 

..  Diss.   Berlin,   1896 
Uber   Brusthohlen 
geschwiielste 


M 


M 


M 


LUNG    IN- 
VOLVED 


41 


52 


57 


48 


R 


R 


R 


CLINICAL   SYMPTOMS 


Grandmother  and  2  aunts  died  of 
cancer.  Commenced  with  pain  in  left 
side.  Aspiration:  clear  serum.  Pa- 
tient worked  for  3  weeks,  then  pain, 
cough,  fever,  and  night  sweats.  Dul- 
ness  over  left  chest.  Dulness  an- 
teriorly to  nipple;  bronchial  respira- 
tion over  apex;  absence  of  breathing 
over  rest  of  lung.  Heart  displaced 
to  right.  Good  appetite.  Dry  cough. 
Aspiration  negative.  Dysphagia  later; 
haemoptysis.  Malignancy  suspected. 
Duration  about  5  months 

Always  well.  Sick  since  7  months 
before  admission  when  lipoma  size  of 
hen's  egg  was  removed  from  posterior 
right  chest.  Tumor  not  examined 
microscopically.  Three  weeks  after 
admission  anterior  right  chest  showed 
impaired  respiratory  motion  and  a 
zone  of  dulness  with  bronchial  respira- 
tion from  2d  to  5th  rib  and  from 
axilla  to  margin  of  sternima.  Diag- 
nosis of  cancer  of  lung  was  made. 
Patient  lost  sight  of  for  4  months,  then 
great  marasmus,  paralysis  of  right  vo- 
cal cord,  pleuritic  pain  in  right  side; 
no  fever.  Dulness  extended  to  pos- 
terior and  lateral  wall  of  thorax. 
DyspncEa 


No  clinical  history 


Commenced  with  chill,  pain  in 
right  chest,  cough,  dyspnoea,  general 
cachexia.  Dulness  increasing  to  flat- 
ness over  entire  right  chest.  _  Di- 
minished breathing  and  fremitus; 
stridorous  respiration.  Paralysis  of 
recurrent.  Appearance  of  tumor  above 
sternum.  Enlarged  axillary  and  cer- 
vical glands.  Right  radial  pulse 
smaller  than  left.  Duration  of  disease 
about  5  months 


CARCINOMA 


201 


Prune  juice 

sputum, 
many- 
tubercle 
bacilli; 
pieces    of 
necrosed 
lung 
tissue 
coughed 
up  with 
haemor- 
rhage 

Always 
"currant 
jelly." 
No  tuber- 
cle bacilli, 
but  on 
first  ad- 
mission 
showed 
numer- 
ous large 
flat  poly 
mor- 
phous 
cells  from 
which  di- 
agnosis 
was  made 

No  details 


tery  flattened  and  com- 
pressed ;  pulmonary  vein  ob- 
literated. Tumor  enclosed 
and  compressed  upon  lower 
trachea  and  aorta  and  prO' 
truded  into  cavity  of  peri' 
cardium.  Left  innominate 
vein  obliterated 

Left  lung  solid  with  nodu- 
lated tumor  containing  cav- 
ity 


AUTOPSY  NOTES 


METASTASES 


Right  lung  almost  entirely 
transformed  into  hard  mass 
Left  lung  normal 


Right  lung 


Glands  at 
hilus,    liver, 
kidney, 
mesenteric 
glands 


Bloody  effusion  in  right 
pleura.  Right  lung  normal 
in  shape  but  ^  normal  size, 
I  grayish  and  yellowish  white 
throughout;  interstitial  tis- 
sue much  thickened.  Bron- 
chi normal 


Occasion- 
ally 
bloody, 
no  tuber 
cle  bacilli 
or  tumor 
elements 


M1CK08C0PE 


Encephaloid 
carcinoma. 
Tubercle  ba- 
cilli in  cavity 


Alveolar 
structure; 
many  large 
polymorph- 
ous epithe- 
lial cells  simi- 
lar  to  those 
found  in  spu- 
tum.    Pleura 
free 


Left  lung, 
brain, 
lymph 
nodes  at 
hilus 


Primary  carcinoma  of 
right  main  bronchus  pene- 
trating lung  without  sharp 
definition.     Bronchiectatic 
cavities 


Medias- 
tinal,  mes- 
enteric, axil- 
lary,    cervi- 
cal lymph 
nodes  and 
liver 


At  the  autopsy  no 
connection  could  be 
traced  between  scar 
from  lipoma  incision 
and  tumor  of  the 
lung 


TjTjical  cy- 
lindrical 
celled  carci- 
noma.   Prob- 
able origin 
from  smallest 
bronchioles 
and  alveoles 


Alveolar 
structure ;    2 
to  3  layers  of 
smooth  cylin- 
drical cells 


Diagnosis  only  pos- 
sible by  microscope 
without  which  the 
case  would  have  been 
diagnosed  as  chronic 
interstitial  pneumo- 
nia with  acute  fibri- 
nous pneumonia  in 
the  stage  of  gray  hep- 
atization 

Supposed     origin: 
ducts    of  bronchial 
mucous  glands 


202 


TABLE  I 


253 


Log.  cit. 


254 


255 


Log.  git. 


Log.  git. 


256 


257 


258 


M 


M 


M 


Pehls, 

Virchows   Arch.  Vol 

56,  p.  437 
Zur  Casuistik  des  Lun- 

gencarcinoms 


Peerone,  a. 

Arbeiten  aus  dem 
Path.  Inatit.  in  Ber- 
Un,  1906 

Entwickelung    eines 
primaren   Cancroids 
von  der  Wand  einer 
tuberculosen  Lungen 
caverne 

Pertjtz, 

Diss.  Miinchen,  1897 
Zur  Histogenese  des  pri 

maren  Lungencarci- 


M 


47 


LUNG    IN- 
VOLVED 


64 


36 


R 


43 


M 


M 


74 


58 


R 


R 


CLINICAL    SYMPTOMS 


Sudden  onset  with  bronchitis,  cedcema 
of  face,  increasing  dyspnoea,  cyanosis, 
dilatation  of  veins,  pain  in  arms  and 
chest.  At  the  beginning  nothing 
essential  found  in  lungs,  but  absolute 
flatness  over  sternum  extending  to 
both  sides.  Feeble  respiration  over 
all  of  right  chest.  Later  effusion  in 
right  chest.  Heart  dislocated  to  left. 
Aspiration:  clear  serum.  Duration 
about  4  months 

Dyspnoea,  pain  in  left  chest,  back, 
and  arm.  Bulging  of  left  chest,  im- 
paired respiratory  motion.  Flatness 
and  vaiying  areas  of  dulness  over  left 
chest.  Some  fever.  Aspiration:  tur- 
bid serum.  Later  distinct  pulsation 
and  increased  fremitus  over  anterior 
left  chest.  Improvement;  patient 
gets  about.  Gradual  retraction  of 
left  chest;  dulness  again  appears; 
increasing  cachexia.  Duration  about 
10  months 

No  previous  illness.  Sudden  fever, 
pain,  cough,  expectoration.  Some  im- 
provement, then  fever  and  ssrmptoms 
of  left  pleurisy  with  effusion.  Heart 
dislocated  to  right.  Aspiration:  500 
c.c.  bloody  serum;  needle  penetrating 
into  hard  tissue.  Later  chills;  flatten- 
ing and  afterward  bulging  of  left 
chest.  Enlargement  of  supraclavicu- 
lar glands.  Aspiration:  pus.  Resec- 
tion of  rib 

Pain,  anorexia,  chilliness,  fever, 
dyspnoea,  cough.  Expansion  right 
chest;  dulness,  feeble  respiration 
above,  absence  of  breathing  sounds 
below;  no  fremitus.  Liver  displaced 
downward.     Duration  about  3  months 


No  previous  illness.  Commenced 
with  pain  in  left  shoulder;  disappeared 
but  returned  very  severely.^  Bulging, 
impaired  respiratory  motion.  Dul- 
ness, diminished  breathing  and  crack- 
ling rales  over  left  chest.  Tumor 
above  left  clavicle.  General  cachexia. 
Duration  about  one  year 


No  clinical  history 


CARCINOMA 


203 


AUTOPSY   NOTES 


METASTASES 


MICKOSCOPE 


Occasion- 
ally 
bloody, 
neither 
tubercle 
bacilli 
nor  tu- 
mor par- 
ticles 


Mucoid, 
no  tuber- 
cle bacilli; 
no  blood 


Bloody  fluid  in  right 
pleura.  Tumor  nodules  in 
mucous  membrane  of  right 
main  bronchus  connecting 
with  large  masses  surround 
ing  trachea  and  extending 
into  right  chest,  penetrat- 
ing lung  and  compressing  it 
Upper  cava  compressed 


Large  firm  tumor  at  left 
hilus ;   polypoid   tumor 
masses  obstructing  left 
main   bronchus.     Tumor 
penetrates  lung  along 
bronchial  ramifications 


No  others 


Alveolar 
structure ; 
small  cylin- 
drical cells 


Lymph 
nodes  and 
liver 


Pavement 
epithelium 
with  tjTjical 
cancer  nests 


Mostly 
bloody 


Encapsulated    empyema 
Carcinoma  of  left  lung  and 
bronchi.     Carcinomatous 
infiltration  of  pleura 


Bloody 


No  tubercle 
bacilli 


No  details 


Bloody  serum  in  right 
pleura.  Right  main  bron- 
chus and  branches  infil- 
trated and  obstructed  by  tu- 
mor. Cavities  with  thick 
capsules  in  upper  and  lower 
right  lobes 

Tubercular  cavity  at  left 
apex;  wall  of  cavity  pene- 
trated by  tumor  involving 
1st  and  2d  ribs,  and  6th  and 
7th  cervical  and  1st  dorsal 
vertebrae.  Compression  of 
axillary  nerves  and  vessels 


Cavity  in  right  upper 
lobe,  walls  of  which  are 
formed  by  firm  white  tumor. 
Tumor  extends  to  right  main 
bronchus,  wall  of  which  is 
perforated,  one  of  the  per- 
forations   communicating 
with  cavity.     Tumor  pene- 
trates into  upper  cava 


Muscles  of 
chest,   liver, 
kidneys, 
capsule  of 
spleen 


Posterior 
mediastinal 
lymph 
nodes,  liver, 
ribs,  inter- 
costal   mus- 
cles, brain 

No  others 


Alveolar 
structure; 
pavement 
epithelial 
cells 


Alveolar 
structure ; 
cancer  nests 


Tubercular 
tissue  with 
bacilli  in  wall 
of  cavity  be- 
sides typical 
cancer  pearls. 
Bronchi 
intact 


No  other 
details 


Alveolar 
structure;  cy- 
lindrical and 
cuboid  cells 
with  forma- 
tion   of  mu- 
cus.    Origin 
bronchial  mu- 
cous glands 


Supposed    origin 
from  bronchus 


204 


TABLE   I 


NO. 

AUTHOR 

SEX 

AGE 

LUNG    IN- 
VOLVED 

CLINICAL    SYMPTOMS 

259 

Loc.  CIT. 

M 

50 

L 

No  clinical  history 

260 

LOC.  CIT. 

F 

48 

L 

Diagnosis  made  during  life  from 
expectorated  tumor  particles 

261 

PiTINI  &  MeBCADANTE, 

La     Reforma     Med. 
Roma,  Vol.  Ill,  1902, 
p.  710 
Carcinoma  midollare 
primitivo  del  polmone 

F 

37 

R 

SjTjhilis  admitted.  On  admission 
cyanosis  of  face,  cedcema  of  right  arm, 
forearm,  and  hand.  For  about  6 
months  harassing  dry  cough,  and  pain 
in  right  shoulder.  Later  cough  be- 
comes moist.  Increasing  dyspncea, 
irregular  dulness  over  greater  part  of 
right  chest  from  above  downward; 
diminished  fremitus;  bronchial  respi- 
ration; many  rales.  All  other  organs 
healthy.  No  leucocytosis;  red  cells 
3,500,000.  Later  swelling  of  right 
thorax  and  arm,  dulness  and  absence 
of  voice  all  over;  diminished  breathing. 
Still  later  all  signs  of  effusion  in  pleura. 
Diagnosis  of  solid  tumor  of  lung  was 
made.     Under  observation  21  days 

262 

Pitt, 

London  Path.  Trans. 

39,      p.      54      (After 

Paessler) 
Malignant    Disease    of 

Bronchial  Glands 

F 

67 

R 

No  clinical  history 

263 

PUECH, 

Montpellier    Med.    2 
me   SSrie,   XI,   1888, 
July,  p.  6 
Cancer  de  la  Trach6e  et 
Tuberculose     pulmo- 
naire 

M 

67 

R 

No  heredity.  Disease  commenced 
with  severe  bronchitis,  general  weak- 
ness, fever,  diarrhoea.  Tubercular  cav- 
ity right  apex.  Duration  about  9 
months 

264 

Reinhardt, 

Arch,  der  Heilk.   19, 

1878,  p.  369 
Primarer  Lungenkrebs 

M 

47 

R 

CEdoema  of  upper  half  of  body. 
Hoarseness,  dyspnoea,  dysphagia.  Di- 
lated veins  on  posterior  and  anterior 
surface  of  chest.  Dulness  over  right 
upper  lobe;  diminished  breathing  an- 
teriorly; bronchial  behind.  No  rales. 
Effusion  in  right  chest.  Little  cough; 
some  fever.  Erysipelas  of  chest. 
Death.     Duration  about  5  weeks 

CARCINOMA 


205 


SPUTUM 

AUTOPSY    NOTES 

METASTASES 

MICBOSCOPE 

HEMAHKS 

No  details 

Left  upper  lobe  almost  en- 

Regionary 

Alveolar 

tirely  replaced  by  large  nod- 

lymph 

structure ; 

ulated  tumor  protruding  in- 

nodes and 

polymorph- 

to mediastinum.     In  centre 

wall  of  left 

ous  epithelial 

of  tumor  a  cavity  into  which 

ventricle 

ceUs;   tumor 

bronchus  of  upper  left  lobe 

injection  of 

opens.     Left    upper    bron- 

lymph ves- 

chus infiltrated  with  tumor 

sels 

nodules 

Tumor  par- 

Left main  bronchus  infil- 

Bronchial 

Carcinoma- 

ticles 

trated  with  tumor;    lung 

and  tra- 

tous struc- 

studded  with   small  tumor 

cheal  lymph 

ture 

nodules;  larger  tumor  at 

nodes;  both 

apex  left  lower  lobe 

kidneys 
brain 

Abundant, 

Abundant  serous  effusion 

Left  lung, 

Typical  epi- 

Nearly all  the  usual 

mucopu- 

in pleurae  and  pericardium. 

axillary. 

thelioma. 

symptoms  of  pulmo- 

rulent. 

Left  lung  studded  with 

peribron- 

Massive  new 

nary    carcinoma    ab- 

Nothing 

larger    and    smaller    tumor 

chial  lymph 

formation   of 

sent  —  no    character- 

charac- 

nodules.    Upper  part  right 

nodes. 

fibrous  tissue; 

istic  bloody  sputum. 

teristic 

lung  firmly  adherent  to 

Right  sub- 

mucoid and 

no  haemorrhagic  exu- 

chest   wall ;    numerous 

clavian 

colloid  degen- 

date in  pleura;  no  ca- 

smaller nodules  throughout 

compressed. 

eration  with- 

chexia 

lung,    but  upper    lobe    one 

All  other 

in  the  new 

large  mass  of  tumor 

organs  nor- 
mal 

formed  tumor 
masses.    Car- 
cinomatous 
structure  in 
secondary 
lymph  nodes. 
Lung  tissue 
completely 
replaced  by_ 
tumor.     Ori- 
gin attrib- 
uted to  alve- 
olar epithe- 
lium 

No  details 

Carcinoma  of  right  main 
bronchus    considerably    ob- 
structing lumen 

No  details 

No  details 

Profuse 

Left  lung  normal.     Tu- 

Peribron- 

Alveolar 

Tumor  evidently 

haemop- 

bercular cavities  right  lung. 

chial  lymph 

structure ;  flat 

gave  no  recognizable 

tysis 

White  tumor  in  trachea  near 
bifurcation,   extending  into 
right    main    bronchus  _  and 
partially   obstructing    it 

nodes 

epithelial 
cells 

clinical  symptoms 

None 

Wall  of  right  bronchus 
penetrated  by  tumor  start- 
ing from  hilus.     Infiltration 
of  upper  lobe  along   bron- 
chial   ramifications.     Com- 
pression of  upper   cava 

Lymph 
nodes  at  bi- 
furcation 

No  details 

206 


TABLE   I 


265 


266 


267 


268 


269 


270 


271 


272 


273 


Reinhardt, 
Sections  Protocol!  des 
Dresdener  Stadt- 
krankenhauses,  1885, 
No.  83 

Log.  git. 
1858,  232 


Log.  git. 
1861,  108 


Log.  cit. 
1872,  433 


Log.  cit. 
1873,  260 


LOC.   CIT. 


toe.  CIT. 


RiPLET, 

New   York    Med. 
Record,  XVIII,  1880, 
691 
Primary     Infiltrating 
Medullary  Carcinoma 
of  Lung 


RiSPAL, 

Toulouse    MM.    Vol 
II,  p.  305  (1900) 
Cancer  primitif  du  Pou- 
mon 


M 


M 


M 


M 


M 


66 


62 


40 


67 


62 


40 


74 


58 


55 


LUNG    IN- 
VOLVED 


R 


R 


R 


CLINICAL    SYMPTOMS 


No  clinical  history 


No  clinical  history 


No  clinical  history 


No  clinical  history 


No  clinical  history 


Increasing  debility,  cough,  pains  in 
left  chest.  Dulness  and  feeble  breath- 
ing over  lower  left  chest;  tympanitic 
percussion  note  over  upper  portion. 
Duration  of  disease  about  5  months 

Cough,  dyspncBa,  pain  in  back,  ver- 
tigo, anorexia,  and  weakness,  bulg- 
ing of  lower  right  thorax  with  dulness 
and  diminished  voice  and  breathing. 
Above  this  area  tympanitic  percussion 
note  and  bronchial  breathing.  Dislo- 
cation of  heart  and  liver 


No  heredity.  Always  weU.  Com- 
menced with  slight  cough,  pain  in 
sternal  region,  weakness,  and  dyspncsa. 
Dulness  from  left  clavicle  downward 
with  loss  of  fremitus  and  distant  bron- 
chial breathing.  Exploratory  punc- 
ture: small  quantity  bloody  serum 
without  relief  of  dyspncsa.  Duration 
about  4  months 

No  heredity.  Bronchitis  since  in- 
fancy; cough  and  expectoration  al- 
ways. For  3  months  severe  pain  in 
right  chest;  anorexia,  cachexia.  Dul- 
ness at  right  base  with  diminished 
vesicular  murmur.     Only  other  symp- 


CARCINOMA 


207 


No  details 


No  details 


No  details 


No  details 


No  details 


Mucoid 


Purulent 
and 

bloody, 
one 

haemop- 
tysis 


Mucous 


Abundant, 
yellowish 
purulent 


AUTOPSY  NOTES 


Large  tumor  in  left  lower 
lobe,  softened  in  centre.  Ob 
struction  of  main  bronchus 


Tumor   of   left   hilus. 
Bronchiectatic  cavity  lower 
lobe;     also   nodule   in   left 
lower  lobe 

Bloody   fluid   in   right 
pleura.     Large  round  tumor 
in  middle  lobe  involving  up- 
per and  lower  lobes.     Bron- 
chi run  freely  through  tu- 
mor;  rest  of  lung  com- 
pressed.    Tumor  extends  to 
heart  and  compresses  upper 
cava  and  pulmonary  vein 

Large  cavity  in  left  lower 
lobe  surrounded  by  wall  of 
tumor  with  papillary  excres- 
cences proliferating  into  in- 
terior of  cavity 

Primary   carcinoma   of 
main  bronchus  of  left  lower 
lobe.     Carcinomatous  infil 
tration  of  the  lobe.     Effu- 
sion in  left   pleura 

Solid  tumor  at  hilus  of  left 
lung  occluding  bronchus  and 
compressing  large  vessels 


Entire  right  lower  lobe 
converted  into  a  large  sac 
filled    with    pus    and    com- 
municating with  main  bron- 
chus.    Walls  of  the  sac  con- 
sist of  tumor.     Walls  of 
bronchus  infiltrated   with 
tumor  and  obstructed 

Bloody  serum  in  left 
pleura.     Almost  entire  left 
lung  solidified.     Right  lung 
also  infiltrated 


Large  tumor  in  lower  lobe 
Softened  in  spots.  Chalky 
tubercles  in  left  lung 


METASTASES 


Brain 


No  details 


No  details 


No  details 


No  details 


Bronchial 
and  tracheal 
lymph 
nodes 


Liver,  peri 
toneum,  tra^ 
cheal  lymph 
nodes 


Bronchial 
lymph 
nodes. 
Both  kid- 
neys 


Pleura, 
heart,  peri- 
bronchial, 
tracheal, 
and  medi- 
astinal 


MICROSCOPE 


No  details 


No  details 


No  details 


No  details 


No  details 


No  details 


No  details 


Medullary 
carcinoma 


Thick,  fi  , 
brous  matrix 
bounding 
cavities  filled 
with  epithe- 
lioid cells. 


208 


TABLE    I 


274  Rosenthal, 

..  Diss.  Miinchen,  1899 
Uber     einen     Fall    von 
primarem     Lungen- 
carcinom 


275  ROTHMAN,  C. 

Deutsch.    Med.    Wo- 
chenschr.    1893,    No. 
35,  p.  844 
Primares     Lungencar- 
cinom    (Demonstra- 
tion) 


276  ROTTMANN, 

Diss.    Wiirzburg, 
1898 
Uber  primares  Lungen- 
carcinom 


277 


278 


Log.  git. 


Rowan,  John, 

Transact.     Ophthal. 
Soc.  of  United  King- 
dom, Vol.  XIX,  1899, 
p.  103 


M 


M 


M 


M 


52 


56 


35 


57 


55 


lung  in- 
volved 


R 


CLINICAL    SYMPTOMS 


toms    digestive    disturbances,    consti- 
pation,   and    polyxiria 


No  heredity.  Gradual  hemiplegia 
of  right  side  with  aphasia,  convulsions, 
and  other  cerebral  symptoms.  Later 
some  dyspnoea.  Nothing  found  on 
lungs.  Later  bronchitis  with  fever  and 
cough;  symptoms  of  vocal  paralysis. 
Duration  about  6  months.  Entire 
clinical  picture  dominated  by  cerebral 
symptoms;  no  lung  s5miptoins  except 
cough  and  dyspnoea 

Slight  haemoptysis  at  17.  A  year 
before  admission  bloody  expectoration, 
but  nothing  could  be  found  in  heart 
or  _  lungs.  Good  appetite;  gained 
weight.  Later  dyspnoea,  cedcEma  of 
face  and  right  arm,  dilated  veins  of 
chest.  Dulness  and  diminished  respi- 
ration over  right  apex.  Haemorrhages 
almost  without  interruption  for  f  of 
year.  Sudden  death  from  oedoema  of 
glottis.  Probable  tumor  diagnosed 
during  life.  Duration  of  disease  a 
little  more  than  a  year 

No  heredity.  Pain,  dulness,  dimin- 
ished breathing  and  voice  sounds. 
Exploratory  puncture  negative.  Sud- 
den paralysis  of  both  lower  extremities. 
Fever,  dyspnoea,  death  in  collapse 


Cough,  anorexia,  emaciation.  Physi- 
cal examination  of  lungs  practically 
negative 


Pulmonary  affection  _  for  4  months 
before  admission.  Initial  haemoptysis; 
cough.  Impaired  respiratory  motion 
of  right  chest.  Dulness  behind  to  _6th 
dorsal  vertebra;  diminished  breathing. 


CARCINOMA 


209 


SPUTUM 

AUTOPSY  NOTES 

METASTASES 

MIGROSCOPE 

BEMABKS 

lymph 

mainly    poly- 

nodes 

hedral;  many 
necrotic  or 
undergoing 
fatty  degener- 
ation.    Peri- 
pheral zone  of 
tumor  shows 
alveolar 
stroma  infil- 
trated with 
small  round 
cells;  alveolar 
spaces  con- 
tain polymor- 
phous cells 

Mucoid 

Carcinoma  of  left  main 

Brain,  bron- 

Alveolar 

Origin  from  epithe- 

bronchus  perforating  wall 

chial,  and 

structure 

leum      of     bronchial 

and  extending  into  left  lung. 

tracheal 

well  devel- 

mucous membrane 

Compression  and  thrombo- 

lymph 

oped  stroma; 

sis  of   right  pulmonary  ar- 

nodes, wall 

typical  cylin- 

tery 

of  left  ven- 
tricle of 
heart 

drical  cells 
with  some  de- 
generation in 
centres  of  cell 
nests 

Bloody,  no 

Infiltrating  carcinoma  of 

Pericardium 

No  details 

tubercle 

right  upper  lobe 

bacilli; 

profuse 

hsemop- 

tysis  for 

almost  f 

year 

Occasion- 

A large  tumor  and  con- 

Bronchial 

Transition 

Origin  probably 

ally 

nected  with  it  a  smaller  one 

lymph 

from  cylin- 

from   bronchial    mu- 

bloody 

in  left  lung.     Large  tumor 

nodes  and 

drical  to 

cous  glands 

contains   cavity  filled    with 

bodies  of 

pavement 

tumor  material  and  pus. 

7th  and  8th 

epithelium 

Tumor  proliferation  into 

vertebrae. 

can  be  dem- 

pulmonary vein  and  left 

compressing 

onstrated 

auricle 

cord 

Purulent 

Emphysema  and  purulent 
bronchitis.     Large  tumor  in 
left  lower  lobe  and  another 
between  upper  and  lower 
lobes 

Right  lung 

Pavement 
and  poly- 
morphous 
epithelium 
and  abundant 
elastic  fibres 
in  stroma 

Bloody,  no 

Left  lung  normal.     Pecu- 

Bronchial 

Irregular 

Author    believes 

tubercle 

liar  fibrous  induration  along 

glands  and 

cells  arranged 

origin  to  be  from 

bacilli. 

bronchi  of  right  lung  extend- 

left eye.  No 

somewhat  in 

glandular  or  mucous 

Many 

ing  through  to  left  lower 

other  metas- 

form of  glan- 

structure of  bronchi 

fatty 

lobe  and  adherent  to  peri- 

tases 

dular  acini 

15 


210 


TABLE   I 


279 


280 


281 


282 


283 


Metastatic  Carcinoma 
of  the  Choroid  from  a 
Primary  Carcinoma 
of  the  Lung 


Rubinstein, 

Wratsch.    1898,    No. 

32.      Centralbl.     f. 

path.     Anat.  Vol.  X, 

1899,  p.  240 
Zur     Frage     iiber     die 

Histogenese   des  pri- 

maren  Lungenkrebses 

Sabolodnow, 
Gesellschaft  der 
Aerzte  an  der  Univer- 
sit.  Kasan.  Die  Med. 
Woche,  Berlin,  1902, 
p.  457 

Ein  Fall  von  primarem 
Lungencarcinom 


Sadowski, 

Centralbl.    f.    Grenz- 

geb.  1900,  p.  781  _ 
Beitrage  zur    Casuistik 

der  Neubildungen  der 

Bronchien 

Sard,  J.  H.  et  Oulie,  A. 
Toulouse  Med.  1901, 
2  s.  Vol.  Ill,  p.  109 

Un  Cas  de  Cancer  pri- 
mitif  du  Poumon 


SCHAPER, 

Vir chows  Arch.  Vol. 
..  129,  1892,  p.  61 
Uber     eine     Metastase 
eines  primaren  Lun- 
genkrebses 


M 


M 


M 


M 


61 


63 


40 


51 


64 


LUNG    IN- 
VOLVED 


R 


R 


CLINICAL    SYMPTOMS 


DuU  tympanitic  sound  all  over  right 
chest  in  front.  No  dyspnoea.  Cervical 
glands  enlarged  over  both  clavicles.  No 
pain.  No  history  of  lues.  Details  of 
examination  of  left  eye  are  given.  Di- 
agnosis of  malignant  disease  of  the  lung 
made  during  life.  Sudden  death  about 
3  weeks  after  admission.  Duration  of 
disease  about  5  months 


No  clinical  history 


No  clinical  history  except  statement 
that  there  was  arteriosclerosis  and  pa- 
ralysis of  recurrent  laryngeal  and  that 
diagnosis  of  carcinoma  of  left  upper 
lobe  was  made  during  life 


Attack  of  pleurisy  with  recovery. 
Second  attack  after  5  months.  Aspi- 
ration 300  c. c.  bloody  serum ;  later  pus. 
Resection  of  rib  showed  tumor 


Admitted  in  semicomatose  condi- 
tion. Slightest  touch  painful,  hence 
only  very  superficial  examination  could 
be  made.  Some  dyspncea.  Heart 
feeble.  Numerous  enlarged  glands  in 
carotid  notches  and  in  subclavicular 
region.  At  level  of  right  parotid  a 
hard  painless  tumor;  skin  movable 
over  it.     Patient  died  next  morning 

Admitted  with  apoplexy.  Dulness 
of  entire  posterior  left  lung,  also  over 
considerable  part  anterior  portion  left 
chest.     No  other  clinical  data 


CARCINOMA 


211 


SPUTUM 

AUTOPST    NOTES 

METASTASES 

MICHOSCOPE 

BEMARKH 

granular 

cardium.    Bronchi  consider- 

Cancer infil- 

cells. 

ably  narrowed 

trates  mucous 

Haemop- 

membrane of 

tysis 

bronchi  and 
surrounding 
lung  tissue 

No  details 

Carcinoma  of  left  hilus 

No  details 

Alveolar 
structure ; 
cuboid,  pave- 
inent,  and  cy- 
lindrical cells; 
pearls  also 
found 

'  Author   considers 
tumor  of  alveolar  ori- 
gin 

No  details 

Left  pleura  closely  adher- 

Bronchial 

Very  thick 

Author  believes  al- 

ent.    Both  upper  and  lower 

glands 

fibrous 

veolar  epithelium  to 

left  lobes  uniformly  enlarged 

stroma  sur- 

be origin  of  tumor 

and  lung  tissue  replaced  by 

rounding 

small  soft  white  nodules, 

small  cavities 

confluent  or  separated  by  fi- 

of the  size  of 

brous  tissue 

pulmonary  al- 
veoles. These 
are  filled  with 
cuboid,  cy- 
lindrical and 
polygonal 
epithelioid 
ceUs.     The 
cells  are  ar- 
ranged in  a 
somewhat 
papillary 
form  over 
strands  of  fi- 
brous tissue 

None 

Carcinoma  of  right  bron- 

None men- 

Carcinoma 

chus  with  abscesses  in  right 

tioned 

keratodes 

lung 

None 

Entire  upper  lobe  of  right 

Parotid 

Simply 

lung  converted  into  a  block 

glands 

stated : 

of  grayish  lardaceous  tissue 

tumor  was 

without   a   trace  of   pulmo- 

epithelioma 

nary   structure.      All  other 

of  lung 

organs  entirely  normal,  even 

those  of  mediastinum.     The 

parotid  tumor  is  only  a  mass 

of  hypertrophied  glands 

No  details 

Large  tumor  starting  from 

Bronchial 

Alveolar 

root  of  left  lung  proliferat- 

lymph 

structure; 

ing  into   lung  tissue   along 

nodes  and 

irregular 

bronchial  ramifications 

myoma  of 
uterus 

polymor- 
phous epithe- 
lial cells 

212 


TABLE   I 


284 


285 


286 


287 


288 


289 


290 


SCHLERETH, 

Diss.  Kiel,  1888 
(After  Passler) 
Zwei  Falle  von  prima- 
rem  Lungenkrebs 

Log.  cit. 


Schmidt, 

Diss.  Jena,  1899 
Zur  Casuistik  des  pri- 

maren  Lungenkrebses 


Log.  cit. 


SCHNOBB, 

Diss.  Erlangen,  1891 
(After  Passler) 
Fall  von  primarem 
Lungenkrebs 

SCHOTTELIXJS, 

Diss.  Wiirzburg,  1874 
Ein  Fall  von  primarem 
Lungenkrebs 


ScHREiBER,  Andreas, 
..  Diss.  Munchen,  1906 
tJber   einen    Fall   von 
primarem  Gallert- 
carcinom  der  Lunge 
mit  Metastasen  im 
Gehim 


M 


Not 


M 


M 


M 


55 


stated 


61 


52 


42 


42 


44 


LUNG    IN- 
VOLVED 


Uncer- 
tain 


R 


R 


R 


CLINICAL    SYMPTOMS 


No  clinical  history- 


No  clinical  history 


No  heredity.  Cough,  pain,  dysp- 
noea, cyanosis.  Enlarged  cervical 
glands.  Dulness  with  diminished  fre- 
mitus, impaired  respiratory  motion, 
feeble  bronchial  breathing.  Two  tap- 
pings bloody  serum.  Sudden  death. 
Duration  of  disease  about  16  months 


No  heredity.  Cough,  dyspnoea,  pain. 
Dulness  over  left  chest;  diminished  or 
absent  breathing.  Heart  dislocated  to 
right.  Cachexia.  Aspiration:  bloody 
serum  containing  characteristic  tumor 
cells.  Sudden  death.  Duration  of  dis- 
ease about  6  months 

No  clinical  history 


No  clinical  history 


Disease  commenced  with  cough  and 
pain  in  chest.  Clinical  diagnosis: 
pleurisy.  Sick  for  9  months;  then 
purely  cerebral  symptoms  —  headache, 
projectile  vomiting,  paralysis  of  left 
side,  strabismus.  No  fever;  no  cough; 
no  signs  on  lungs  except  slight  dulness 
over  left  apex.  Clinical  diagnosis: 
tuberculosis  of  right  cerebral  hemi- 
sphere 


CARCINOMA 


213 


SPUTUM 

AUTOPSY    NOTES 

METASTASES 

MICEOSCOPE 

REMARKS 

No  details 

In   both   lungs   and   pul- 
monary   pleurae,    numerous 
nodules  of  all  sizes  down  to 
miliary.     Bronchial    walls 
not  involved 

No  details 

Alveolar 
structure ; 
mostly  cylin- 
drical cells; 
somie  flat 

No  details 

Irregularly  defined  tumor 
in  right  lower  lobe  extending 
from  root  through  lung  to 
pulmonary  pleura 

No  details 

Cylindrical 
cells 

Bloody,  no 

Nodulated  tumor  contain- 

Right lung. 

No  details 

Left    lung    had    3 

tubercle 

ing  cavity  in  left  middle  and 

both  pleurse. 

lobes 

bacilli 

lower  lobe.     Bronchial  walls 
infiltrated  with  tumor 

bronchial 
and  portal 
lymph 
nodes,  gas- 

tro-hepatic 

ligament. 

and  right 

kidney 

No  details 

Tumor  at  root  of  lung  fol- 
lowing ramifications  of 
bronchi.     Bronchiectases. 
Thrombosis    of    pulmonary 
artery 

Liver,  kid- 
neys, right 
suprarenal 

No  details 

No  details 

Tumor  along  ramifications 
of  bronchi  involving  almost 
entire  right  lung,  also  pleura 
and  pericardium 

Left  lung, 
cervical  and 
axillary 
lymph 
nodes 

No  details 

No  details 

Clear  serum  in  right 

Substernal, 

Lymphangi- 

The   miliary    nod- 

chest; bloody  serum  in  peri- 

tracheal and 

tis  carcino- 

ules  throughout  lung 

cardium.     Entire  right  lung 

bronchial 

matodes 

and  pleura  are  ar- 

firm, without  air  and  stud- 

lymph 

ranged  in  an  anasto- 

ded with  numerous  nodules 

nodes. 

mosing  reticulum 

up  to  size  of  walnut 

Pleura,  peri- 
cardium, 
beginning  of 
aorta  and 
pulmonary 
artery 
studded 
with  miliary 
nodules 

corresponding  to  the 
lymphatics.      Author 
attempts  to  establish 
origin  of  tumor  from 
endothelium  of  lym- 
phatics 

None 

Tumor  left  lower  lobe 

Brain,  both 

Gelatinous 

Author  assigns 

adrenals. 

gland-like  tu- 

origin   to   alveolar 

left  kidney, 

bules  con- 

epithelivmi 

both  ovaries 

taining  much 
mucoid  ma- 
terial. Bron- 
chial epithe- 
lium and 
bronchial  mu- 
cous glands 
normal.    Me- 
tastases same 
structure 

214 


TABLE   I 


291 


292 


293 


294 
295 


296 


297 


298 


Schroder,  Hugo, 
Diss.  Kiel,  1902 

Ein  Fall  von  primarem 
Krebs  der  Lunge 


SCHWALB,   HeINRICH, 

Diss.  Wiirzburg,  1894 
Ein  Fall  von  primarem 
Lungencarcinom 


Schweninger, 

Annalen    des    Stad. 
Krankenhauses  in 
Miinchen,      1876-77. 
Vol.  II,  367 


Loc.  CIT. 


Sehrt, 

Diss.  Leipzig,  1904 
Beitrage  zur  Kenntniss 

des    primaren    Lun 

gencarcinoma 


Loc.  CIT. 


Loc.   CIT. 


SlEGEL, 

Diss.  Miinchen,  1887 
(After  Passler) 
Zur  Kenntniss  des  Pflas 
terepithelkrebses   der 
Lungen 


M 


M 


M 


34 


LUNG   IN- 
VOLVED 

Both 

(?) 


60 


49 


62 
66 


75 


68 


63 


Probably 
L 


CLINICAL  SYMPTOMS 


Pneumonia  with  incomplete  absorp- 
tion. Thereafter  occasional  fever; 
gradual  development  of  cedoema  in  ter- 
ritory of  upper  cava.  Cough,  cyanosis, 
dyspnoea.  Ronchi  over  both  lungs,  but 
nothing  characteristic.  Later  ascites, 
enlarged  liver,  albuminuria,  and  hya- 
line casts.  Clinical  diagnosis:  myocar- 
ditis after  pneumonia.  Death  from 
erysipelas  and  peritonitis.  Duration 
of  disease  about  15  months 

Always  well.  For  a  few  months 
dyspnoea,  cough,  sense  of  suffocation. 
On  admission  great  emaciation;  some 
cyanosis  and  fever.  Pneumonia  of  left 
lower  lobe;  bronchitis.  Death  after 
2  days 


No  clinical  history  except  that  pa- 
tient was  sick  for  2  years  with  symp- 
toms of  chronic  pulmonary  phthisis 


R 


No  clinical  history 
No  clinical  history 


Clinical    diagnosis'  pleuro-pneumo- 

nia 


Intense  dyspnoea.  Dulness  over  en- 
tire left  chest  with  harsh  respiration 
and  rales.  Death  from  profuse  and 
sudden  haemorrhage.  Clinical  diagno- 
sis: phthisis 


No  clinical  history 


CARCINOMA 


215 


SPUTUM 

AUTOPST   NOTES 

METASTASES 

MICROSCOPE 

REMARKS 

Mucoid 

Chronic  induration  of 

None 

Hsemor- 

No    clinical   symp- 

both   lungs.     Pneumonic 

rhagic  areas. 

toms  pointing  to  tu- 

consolidation of  right  lower 

typical  carci- 

mor;   diagnosis   only 

lobe ;  pleurisy  on  left.  Hasm- 

noma  prob- 

possible with    micro- 

orrhagic areas  in  both  lungs 

ably  from 

scope  at  autopsy 

diagnosed  macroscopically 

bronchial  epi- 

as  infarctions,  but  micro- 

theUum and 

scopically  proved  to  be  typi- 

extending 

cal  carcinoma 

along  lymph 
channels 

Profuse 

Turbid  serum  in  left 
pleura.     Tumor  size  of  an 
apple  in  left  lower  lobe,  sur- 
rounded  by  inflamed   lung 
tissue.      Tumor  is   whitish 
gray,  sharply  defined  against 
surrounding   lung   tissue. 
Firm   fibrous  masses  inter- 
spersed with  soft,  very  cellu- 
lar portions  of  tissue 

No  details 

Alveolar 
structure 

No  details 

Tumor   nodules  in   both 
lungs 

No  details 

Carcinom- 
atous struc- 
ture; cylindri- 
cal and  poly- 
morphous 
cells 

No  details 

Primary  cancerous  tumor 
of  left  upper  lobe 

No  details 

No  details 

No  details 

Carcinoma  of  right  main 

Bronchial 

Alveolar 

bronchus  and  of  cavity  at 

and  tracheal 

structure; 

hilus  of  right  lung  with  ero- 

lymph 

pavement 

sion  of  pulmonary  artery 

nodes 

epithelium. 

and  acute  lethal  haemor- 

cancer pearls; 

rhage.    Bronchiectases.  Ex- 

patches of  ne- 

tensive chronic  ulcerative 

crosis 

tuberculosis 

No  details 

Bloody  fluid  in  pleura. 

Both  lungs. 

Horny  pave- 

Carcinoma of  right  lung 

left  ventri- 

ment epithe- 

with gangrenous  cavity  and 

cle,  left  adre- 

lium 

chronic   indurative   pneu- 

nal, and  6th 

monia.     Carcinomatous 

rib 

thrombosis  of  pulmonary 

artery 

Hsemopty- 

Carcinoma  of  left  main 

Bronchial 

Pavement 

sis 

bronchus  with  extension  to 
left  pleura,  bronchial  Ijonph 
nodes,  and  large  branch  of 
pulmonary  artery.    Chronic 
ulcerative  tuberculosis  of 
left  upper  lobe 

lymph 
nodes  and 
oesophagus 

epithelium 

No  details 

Large  tumor  in  left  upper 

Both  lungs 

Large  polyg- 

and lower  lobes 

and  left 
pleura 

onal  cells 

216 


TABLE   I 


299 


300 


301 


302 


303 


304 


305 


Loc.  CIT. 


SlEGEHT, 

Virchows  Arch. 
1893,  134 
Zur  Histogenese  des  pri- 
maren  Lungenkrebses 


Singer, 

Prag.  med.  Woch. 

1885,  pp.  329-341 
Drei  Falle  von  intra- 

thoracischem  Tumor 


Singer, 

Diss.  Berlin,  1908 
Zur  Klinik  der  Lungen- 

carcinome 


Loc.    CIT. 


Loc.   CIT. 


SiROTINI, 

Wratsch.  St.  Peters- 
burg, 1905,  Vol.  72,  p. 
58.  Lubarsch-Oster- 
tag,1907,Ht.  2,p.  734 
Two  Cases  of  Primary 
Cancer  of  Lung 


M 


M 


M 


Not 


53 


60 


41 


80 


77 


stated 


LUNG    IN- 
VOLVED 


R 


R 


R 


CLINICAL    SYMPTOMS 


No  clinical  history 


Admitted  5  days  before  death  suf- 
fering from  hemiplegia  of  right  side, 
aphasia  and  pleurisy  with  hsemor- 
rhagic  effusion  in  left  side 


Sudden  onset  with  dyspnoea,  cough, 
and  increasing  debility.  Later  dila- 
tation superficial  veins.  Dulness  at 
right  apex  with  bronchial  respiration 
in  front;  no  breathing  sounds  pos- 
teriorly. Pain;  harassing  cough.  Du- 
ration about  3  months 


No  heredity.  Previous  history  neg- 
ative, but  had  lung  trouble  for  some 
years.  Cough,  dyspnoea  on  exertion. 
On  admission  _  emaciation,  intense 
dyspnoea,  cyanosis;  no  fever;  no  glands. 
Greater  portion  of  left  lung  in  front 
and  behind,  flat;  diminished  voice  and 
breathing.  Nothing  on  right  lung. 
Aspiration:  1200  c.c.  turbid  serum. 
Paralysis  of  left  vocal  cord.  Death 
in    2    days 

No  heredity ;  no  previous  illness.  Re- 
cently weakness,  pain  in  chest.  Dulness 
and  bronchial  respiration  upper  left 
apex.  No  rales.  Right  lung  and  heart 
normal.  Gradually  some  fever;  fine 
crackling  in  left  base.    Sudden  death 

Admitted  in  moribund  condition. 
Intense  dyspnoea  for  some  time,  cyano- 
sis, hoarseness,  some  fever.  No  ca- 
chexia. Tumor  size  of  small  fist 
emerges  above  sternum.  Death  within 
24  hours  after  admission 


No  clinical  history 


CARCINOMA 


217 


SPUTUM 

AUTOPSY    NOTES 

METASTASES 

MICHOSCOPE 

REMARKS 

No  details 

Tumor  in  right  middle 

Bronchial 

Large  polyg- 

lobe 

lymph 
nodes, 
pleura, 
liver,  left 
suprarenal, 
thyroid,  and 
both  kid- 
neys 

onal  cells 

No  details 

Extensive  infiltrating  car- 
cinoma of  left  lung  and  bron- 
chi    simulating    pneumonic 
consolidation.     No  pro- 
nounced tumor  or  nodules. 
Extensive  secondary   carci- 
nosis of  lymphatics 

None 

Alveolar 
structure;  cy- 
lindrical cells 
with  transi- 
tion to  pave- 
ment   epithe- 
lium 

Foul, 

Cavity  with  hsemorrhagic 

Pleura, 

No  details 

Origin  from  bron- 

bloody 

contents  in  right  upper  lobe. 
Walls  consist  of  partially 
necrotic  and  infiltrating  tu- 
mor.    Ulcerated  medullary 
tumor  in  right  main  bron- 
chus and  its  larger  branches, 
obstructing   lumen.     Ob- 
struction of  upper  cava 

liver,  adre- 
nals and  thy- 
roid 

chial  mucous  glands 

Glairy 

Carcinomatous  thrombo- 

Pleura, peri- 

Pavement 

sis  of  left  lower  pulmonary 

cardium. 

cell  carci- 

vein.    Carcinoma  of  left 

bronchial 

noma 

main  bronchus  infiltrating 

and    perito- 

and occupying  the  bronchus 

neal    lymph 

of  left  lower  lobe.     Diffuse 

nodes,  left 

carcinomatous  infiltration  of 

kidney,  left 

left  lower  lobe.    Carcinoma- 

adrenal, left 

tous  infiltration  of  lymphat- 

ovary and 

ics  of  bronchi  of  left  upper 

in  thyroid 

lobe 

Scant, 

Primary   carcinoma   of 

No  details 

No  details 

mucopu- 

lower left  lobe   originating 

rulent, 

from  bronchial  mucous 

no  tuber- 

membrane.    Many    small 

cle  bacUli 

pneumonic  abscesses 

No  details 

Right  upper  lobe  adher- 

Pericar- 

Pavement 

ent  to  sternum  and  to  ribs, 

dium,  right 

cell  carci- 

infiltrated with  hard  carci- 

pleura, ster- 

noma 

noma.     Small   bronchi   and 

num  and 

bronchioles  filled  with  detri- 

upper ribs, 

tus  and  carcinomatous  ma- 

mediastinal 

terial;    also  some  in  upper 

lymph 

cava.     Lymph  channels  in- 

nodes 

filtrated 

No  details 

Multiple  miliary  carci- 

No details 

Flat  epithe- 

Origin supposed 

noma  of  lower  lobe 

lial  cells 

from  alveolar  epithe- 
lium 

218 


TABLE   I 


306 


307 


308 


309 


310 


311 


312 


313 


314 


Log.  cit. 


Smith-Shand, 

British     Med.     Jour 
1875,  I,  844;  II,  41 


Stieb 

..  Diss.  Giessen,  1900 

Uber    das    Plattenepi- 

thelcarcinom  der 

Bronchien 

Loc.   CIT. 


Stilling, 

Virchow's  Arch.  Vol 
LXXXIII,  1881,  p. 

..  77 

ijber  primaren  Krebs 
der    Bronchien     und 
des    Lungenparen 
chyms 


Loc.   CIT. 


Loc.  CIT. 


Loc.  CIT. 


Stobeh, 

Amer.   Jour.   Med 
Sciences     XXI,    46, 
1851 


SEX 

AGE 

LUNG    IN- 
VOLVED 

Not 

stated 

R 

F 

36 

L 

M 

50 

L 

M 

60 

R 

M 

52 

R 

F 

27 

R 

M 

70 

L 

M 

64 

R 

M 

39 

R 

CLINICAL    SYMPTOMS 


Diagnosed  during  life 


Cough,  pain,  hoarseness,  right  hemi- 
plegia. Dulness  over  left  chest;  im- 
paired respiratory  motion;  absence  of 
breathing   sounds 


_  No   clinical  history   except  patient 
died  of  cirrhosis  of  liver 


Cough,  pain,  infiltration  of  right 
apex,  increasing  debility.  Duration  of 
disease  6  to  8  months 


No  clinical  history 


No  clinical  history 


No  clinical  history 


No  clinical  history 


Cough,  dyspnoea.     Dulness  of  lower 
f  right  chest  and  absence  of  breathing 


CARCINOMA 


219 


No  details 


Scant, 
bloody 


No  details 


Moderate, 
mucoid, 
no  tuber- 
cle bacilli 


No  details 


No  details 


i 


No  details 


No  details 


Tenacious 
mucoid 


AUTOPSY  NOTES 


METASTASES 


Primary   carcinoma  of 
walnut  size  in  right  lung 


Left  main  bronchus 
plugged  by  tumor.  Left 
lung  full  of  soft  tumor  ad- 
herent to  pericardium  and 
surrounding  structures  at 
root.  Compression  of  left 
vagus  and  recurrent 

Submucous  carcinoma  in 
bronchus  of  left  lower  lobe 
infiltrating  surrounding  lung 
tissue 


Primary  carcinoma  at  bi 
furcation  of  right  main  bron 
chus.  Gray  hepatization  of 
right  upper  and  middle  lobes 


Large  tumor  of  bronchus 
of  right  middle  lobe  extend- 
ing  into  right  main  bron- 
chus, penetrating  wall  and 
infiltrating  peribronchial  tis 


Bloody  serum  in  right 
pleura.     Polypoid  tumor 
right  main  bronchus  and  in 
upper     bronchus.     Tumor 
nodules  in  both  lungs  and 
in  trachea.     Bronchiectases 
right  upper  lobe. 


Left  main  bronchus  com- 
pletely destroyed  by  tumor 
mass  in  left  upper  lobe  pene- 
trating into  lower 

Upper  and  middle  lobes 
almost  entirely  converted 
into  tumor  infiltrating  along 
blood  vessels  and  bronchi 


Encephaloid  mass  occu- 
pies more  than  J  of  right 
lung.  Contains  small  cav 
ities;    tumor    in    right    pri- 


No  details 


Brain 


Small  poly- 
morphous 
epithelial  cells 
almost  Uke 
sarcoma  cells 

No  details 


Regionary 
lymph 
nodes 


Both  lungs 
supra  clavic- 
ular lymph 
nodes 


Bronchial, 
mediastinal 
lymph 
nodes ;    also 
cervical 
nodes,  peri- 
cardium, 
and  liver 


Bronchial, 
cervical,  and 
retroperito- 
neal lymph 
nodes;  liver 
and  small 
curvature  of 
stomach 

Left  bron 
chial  lymph 
nodes 


Bronchial, 
cervical,  and 
axillary 
lymph 
nodes;  left 
lung,  liver, 
and  left  su- 
prarenal 

Bronchial 
and  tracheal 
lymph 

nodes 


MICROSCOPE 


Origin    bronchial 
mucous  membrane 


Although  no  micro- 
scopic examination  is 
given,  there  is  little 
doubt  that  this  tumor 
is  carcinoma 


Horny  pave- 
ment epithe- 
lium 


Alveolar 
structure ; 
horny     pave- 
ment  epithe- 
lium 

Plexiform 
and    alveolar 
cancer  nests; 
cancerous  in- 
jection of 
lymph  spaces 
and    prolifer 
ation  along 
vascular    and 
nerve  sheaths 

Same  as 
above 


No  details 


No  details 


No  details 


220 


TABLE 


NO. 

ATJTHOB 

SEX 

AGE 

LUNG    IN- 
VOLVED 

CLINICAL    SYMPTOMS 

Carcinoma   of   Right 

Lung  with  Symptoms 

of  Hydrothorax 

315 

Stumpf, 

Diss.  Giessen,  1891 

(After  Passler) 
Zur  Casuistik  des  pri- 

maren  Lungencarci- 

noms 

Not 

stated 

R 

No  clinical  history 

316 

Suckling, 

Lancet.  1884,  1047 
Case    of    Primary    En- 

cephaloid   Growth  of 

Lung 

M 

61 

R 

No  heredity;  no  pain.  Dyspnoea, 
cachexia.  Right  chest  more  volumi- 
nous than  left.  Dulness  over  lower 
right  lobe  with  impaired  respiratory 
mobility  and  absence  of  fremitus. 
Later  on  signs  of  cavity.  Enlarged 
Liver.  First  puncture:  bloody  fluid; 
second  negative 

317 

SZELAG0W3KI, 

Thhse  de  Paris,  1900 
Contribution   a  I'etude 
clinique    du    Cancer 
primitif      pleuro-pul- 
monaire 

F 

47 

L 

No  heredity;  no  serious  illness. 
Commenced  with  loss  of  appetite,  then 
some  general  stiffness  and  malaise;  ver- 
tigo. Later  attacks  of  suffocation.  On 
admission  intense  dyspnoea,  some  cyan- 
osis, bulging  of  left  chest ;  absolute  flat- 
ness behind  to  spine  of  scapula  and  in 
front  to  below  clavicle ;  absence  of  voice 
and  breathing.  Heart  displaced  to 
right  of  sternum.  Right  lung  normal. 
Aspiration:  1000  c.c;  pink  fluid;  slight 
relief.  Repeated  puncture  only  small 
quantity  fluid  and  but  little  relief.  X- 
rays  show  a  lobulated  mass  to  left  of 
vertebral  column  besides  shadow  over 
aU  of  lower  left  lung.  Intense  pain  and 
dyspnoea;  dysphagia,  fever,  delirium. 
Duration  of  disease  about  6  months 

318 

Tillman, 

Diss.  Halle,   1889 

(After  Passler) 
Drei  Falle  von   prima- 

rem  Lungencarcinom 

M 

45 

R 

No  cUnical  history 

319 

Log.  git. 

M 

61 

R 

No  clinical  history 

320 

Log.  git. 

M 

68 

Not 
stated 

No  clinical  history 

u 


CARCINOMA 


221 


No  details 


I 


Profuse, 
whitish ; 
later 
"currant 
jelly" 
haemop- 
tysis. 
Tubercle 
bacilli 

Scant;  no 
tubercle 
bacilli 


No  details 


No  details 


No  details 


AUTOPSY   NOTES 


mary  bronchus, 
gans  normal 


Other  or- 


Tumor  of  right  upper  lobe 
proliferating   along   bron- 
chial ramifications  into  sur- 
rounding   tissue.     At    root, 
tumor  extends  into  main 
bronchus  and  penetrates  in 
to  lumen.     Proliferation  of 
tumor  into  pleura,  pericar 
dium,  right  auricle,  and  large 
vessels  especially  upper  cava 
and  right  pulmonary  artery 

Tubercular  cavity  and 
miliary    tubercles    through- 
out right  lung.     In  lower 
right  lobe  a  large  patch  of 
yellowish  tumor 


Left  pleura  thickened. 
Nearly  whole  of  left  lung  oc 
cupied  by  grayish  white  tu- 
mor softened  and  degener- 
ated in  parts 


Tumor  in  right  lower  lobe 
close  to  large  bronchial 
branch 


Bronchial    carcinoma    of 
lower  lobe  following   bron- 
chial ramifications.      Nu- 
merous  small    secondary- 
nodules   each   surrounding 
small  bronchus 

Primary  medullary   nod- 
ule in  lung.     Numerous  sec- 
ondary nodules  in  brain, 
cerebellum,   and  medulla. 
Nodules  frequently  show 
cystic  degeneration 


METASTASES 


Regionary 
Ijonph 
nodes 


No  details 


Only  lymph 

nodes  at  lu- 
lus 


Alveolar 
tructure ; 
polymorphous 
epithelial 
cells 


No  details; 
author  sim- 
ply says  "epi- 
thelial tu- 


None 


Bronchial, 
mesenteric, 
and  coeliac 
lymph  nodes 
and  liver 


Brain,  cere- 
bellum, and 
medulla 


MICKOSCOPE 


Cylindrical 
cuboid  and 
large  poly- 
morphous 
cells 


Carcinoma 
with  cells  re- 
sembling nor- 
mal alveolar 
cells 

Cylindrical 
cells  with  ten- 
dency to  mu- 
coid degener- 
ation 


Large  cylin- 
drical cells 
with  mucoid 
degeneration 


222 


TABLE   I 


321 


322 


323 


TURNBULL   &   WOETH- 
INGTON, 

Arch.  Path.  Inst. 
London  Hospital,  Vol 
II,  1908,  p.  163 
Two  Cases  of  Carci- 
noma   arising    pri- 
marily in  a  Bronchus 


Loc.  CIT. 


M 


M 


V.  Fetzbb, 

Med.  Correspon- 
denzbl.  des  Wiirten- 
bergischen    arztli- 
chen  Landes  Vereins, 
1905,  p.  139 

Ein  vom  rechten  Bron- 
chus ausgehendes 
Carcinom  der  rechten 
Lunge 


LUNG    IN- 
VOLVED 


55 


66 


M 


36 


R 


R 


CLINICAL   SYMPTOMS 


About  7  months  before  admission 
on  lifting  a  parcel  "something  gave 
way  in  his  back."  Ever  since  pain  in 
back  and  down  legs.  Sweating  and 
wasting  of  legs.  Tenderness  over  left 
lumbar  spine  and  both  sciatica;  no 
impairment  of  sensation.  Increasing 
nervous  symptoms;  fever  up  to  106. 
Later  2  pigmented  spots  on  inner  sur- 
face right  chest  and  several  spots  on 
chest  and  abdomen.  Increasing  ema- 
ciation and  weakness.  Albumin  in 
urine  and  occasionally  a  trace  of  al- 
bumose.  Nothing  is  said  about  physi- 
cal examination  of  lungs 


Always  healthy  until  6  months  be- 
fore admission,  then  pain  in  left  shoul- 
der and  back  after  lifting  heavy  weight. 
Disappeared  for  some  time,  then  reap- 
peared and  persisted  with  occasional 
remissions.  Loss  of  weight,  tender- 
ness on  percussion  of  dorsal  spine; 
anaesthesia  of  8th  left  dorsal  nerve; 
wasting  of  lower  limbs.  Remarkable 
absence  of  physical  signs.  X-rays 
show  apparently  deepened  shadow  to 
the  left  of  upper  descending  thoracic 
aorta  and  2  small  dark  shadows  in 
lower  half  of  right  lung.  Diagnosis  of 
either  aneurysm  or  neoplasm  of  lumbar 
spine  was  made.  Later  on  symptoms 
pointing  to  lungs.  Nothing  said  of 
cough,  sputum,  or  physical  signs  on 
lungs.  Symptoms  mainly  referableto 
spine  —  severe  pains  in  legs,  wasting 
of  legs,  bladder  symptoms,  inconti- 
nence of  faeces,  etc.  Duration  about 
10   months 

Cough,  irregular  fever;  good  appe- 
tite. Dulnesa  at  right  base;  dimin- 
ished voice  and  breathing.  Later  dul- 
ness  over  left  apex  with  bronchial 
respiration.  No  rales.  Patient  feels 
better  and  gains  steadily  in  weight; 
leaves  hospital  having  gained  5  kilos. 
Works  at  his  trade  for  4  months  when 
readmitted  with  severe  dyspnoea,  cya- 
nosis, and  dilated  veins  about  head, 
neck,  chest,  and  upper  extremities. 
Flatness  over  right  chest;  bronchial 
breathing  but  no  rales.  Intercostal 
spaces  levelled;  heart  dislocated^  to 
left.  Enlarged  glands  above  right 
clavicle;  2  tumors  on  left  parietal 
bone.  CEdoema  of  right  arm.  Right 
pupil  dilated.  Duration  of  disease 
about  one  year 


CARCINOMA 


223 


SPUTUM 

AUTOPSY    NOTES 

METASTASES 

MICROSCOPE 

BEMARKS 

Once  a 

Carcinoma  of  bronchus  in 

Retroperi- 

Alveolar 

lump  of 

left  lower  lobe.     On   outer 

toneal,  in- 

structure 

foul- 

surface  both  lungs  many 

guinal,  cer- 

lined with  cy- 

smelling 

hard    miliary    nodules.     In 

vical  and 

lindrical  cells. 

material 

left  lower  lobe  cavity  size  of 

bronchial 

some  cuboid- 

size  of 

walnut  with  ragged  edges 

lymph 

al.     Main 

walnut, 

and  containing  many  white 

nodes,  right 

bronchus, 

looking 

nodules;  communicates  with 

femur,   both 

bronchioli. 

like  "her- 

bronchi of  3d  and  4th  order; 

iliac  bones. 

pulmonary 

ring  roe" 

nodular  thickening  of  mu- 

lumbo-sacral 

arteries  and 

cous  membrane.     Atelecta- 

vertebrae, 

vein  and  sur- 

sis below  cavity.     Nodules 

ribs,  and 

rounding 

in  both  costal  and  visceral 

sternum. 

lung  tissue  in- 

pleura;  adhesions  and  effu- 

Nodules   in 

filtrated  by 

sion  on  both  sides 

both  adre- 
nals and  in 
atrophied 
liver.   Brain 
not    exam- 
ined 

tumor 

No  details 

Carcinoma  of  lower  right 

7th  and  8th 

Acinous 

In  both  cases  singu- 

bronchus.    Carcinomatous 

dorsal  ver- 

structure 

larly    small    size     of 

lymphangitis  of  pleura  of 

tebrae  press- 

with secre- 

primary   tumor   and 

both  lungs.     Bronchitis  and 

ing  on  cord; 

tion  of  mucus 

selection  of  bones  as 

capillary   bronchitis  of  left 

7th  and  8th 

but  greater 

chief  sites  of  second- 

lower   lobe.       Myocarditis, 

left  ribs  and 

part  is  at3T)i- 

ary  growth.   Absence 

acute  endocarditis;    abscess 

8th  right 

cal 

of  physical  signs 

in  spleen;    septic  infarct  in 

rib.     No  en- 

pointing to  lungs  in 

right  kidney.     Solid  nodule 

largement 

both  cases 

at  back  of  right  lower  lobe 

of  lymph 

communicating  with  bron- 

nodes in 

chus 

■ 

chest 

Occasional 

No  details 

No  details 

No  details 

Case  is  interesting 

haemop- 

on account  of  the 

tysis;  no 

steady  gain  in  weight 

tubercle 

during  his  stay  in  the 

baciUi 

hospital 

224 


TABLE    I 


324 


325 


326 


327 


V.    SCHHOTTEH,   H. 

Mitth.  der  Gesellsch.  f. 

inn.  Med.  u.  Kinder- 

hlk.  in  Wien,  1907,  p. 

145 
Demonstration    eines 

Falles  von  Carcinom 

der  Bronchien 


V.    SCHEOTTER,   H. 

Zeitschr.  f.  klin.  Med. 
Vol.  62,  1907,  p.  508 
Zur  Preezisions  Diagnose 
der  Lungentumoren ; 
bronchogenes  Karzi- 
nom  mit  Glykogen- 
bildung ;  Bemerkun- 
gen  zur  Histogenese 
desselben 


M 


328 


WaCHSMANN  &  POLLAK, 

New  York  Med.  Rec 
ord,  Nov.  1904 
Three  Cases  of  Primary 
Malignant  Tumor  of 
the  Lung 


Wagner, 

Miinch.  med.  Woch 

1903,  p.  133 
Primares    Bronchial- 

carcinom 


Waldmann,  Anton, 
Diss.  Miinchen,  1902 

Ueber  primares  Carci- 
nom  des  Lungenpa- 
renchyma 


M 


M 


Not 


M 


LUNG    IN- 
VOLVED 


30 


44 


55 


stated 


R 


R 


CLINICAL    SYMPTOMS 


Most  severe  heemoptyses  for  11 
months.  Perfectly  healthy  until  first 
sudden  haemorrhage  without  apparent 
cause.  Haemorrhage  repeats  at  inter- 
vals of  8  to  14  daj's.  Must  have  ex- 
pectorated about  8000  c.c.  of  blood. 
Repeated  and  most  careful  examina- 
tion showed  no  cause  for  the  bleeding. 
Nose,  throat,  trachea  suspected.  X- 
ray  examination  showed  nothing; 
nothing  found  on  lungs.  Broncho- 
scope found  a  tumor  at  bifurcation  of 
right  main  bronchus  in  right  lower  lobe 

No  heredity.  5  weeks  before  ad- 
mission cough,  pain  in  chest,  loss  of 
weight.  Dilated  veins  left  anterior 
chest  and  abdomen.  Right  chest  lags 
in  respiration;  flatness  over  right  apex 
in  front  from  axillary  line  over  left 
border  of  sternum.  Absence  of  breath- 
ing upper  portion  right  lung;  dimin- 
ished in  lower.  Tumor  suspected  and 
demonstrated  by  bronchoscope  in 
main  bronchus  just  above  bronchus  of 
upper  lobe.  Excision  of  small  piece 
in  bronchoscope  shows  pavement  epi- 
thelium carcinoma.  Cells  contain  gly- 
cogen in  small  round  spheres.  Patient 
feels  better  for  a  time  and  gains  in 
weight.  Later  oedcsma  of  face,  intense 
cyanosis;   death  from  exhaustion 

Cough,  pain,  emaciation,  clubbed 
fingers.     Dulness  over  right  upper  lobe 


No  clinical  details  except  that  there 
was  normal  percussion  note  and  breath- 
ing over  whole  left  lung,  but  that  vocal 
fremitus  was  markedly  diminished,  al- 
most abolished,  and  that  at  a  very 
early  stage  of  the  disease  the  clinical 
diagnosis  of  tumor  of  the  lung  prob- 
ably starting  from  bronchus  could  be 
made 

Emphysema;  bronchitis.  Gradual 
loss  of  weight ;  pain ;  swelling  in  region 
of  liver.  Six  months  later  fever  and 
dulness  over  right  upper  lobe._  Fever 
disappears,  but  dulness  remains  and 
increases.  Two  months  later  cerebral 
symptoms  and  tumor  perforating  skull. 
Duration  about  9  months.  Clinical 
diagnosis:  primary  tumor  of  lung  with 
cerebral  metastases 


CARCINOMA 


225 


AUTOPSY    NOTES 


METASTASES 


MICHOSCOPE 


Severe 
repeated 
hEemop- 
tysis 


No  details 


No  details 


Often 
bloody. 
Later 
hsemop- 
tysis.   No 
tubercle 
bacilli 


Carcinoma  of  right  main 
bronchus  with  carcinoma- 
tous degeneration  of  right 
upper  lobe.  Proliferation 
into  superior  cava.  Indu- 
ration and  cheesy  tubercular 
remnants  in  right  apex.  Tu- 
mor of  lung  contained  cav- 
ity 


Profuse, 
bloody. 
No    hee- 
moptysis. 
Contains 
ceUs  sug- 
gesting 
"tumor 
cells" 

No  details 


Bloody;  no 
tubercle 
bacilli ; 
no  tumor 
elements 


Ulcerated   right   upper 
bronchus;    infiltrating  tu- 
mor following  lymph  chan- 
nels in  lung,  also  in  pleura 


Proliferating  tumor  ob- 
structing lumen  at  final  di- 
vision of  left  main  bronchus 


General  carcinomatosis  of 
left  upper  lobe.  Cancerous 
pleurisy  of  both  sides 


Examination 
of  small  por- 
tion removed 
by  probatory 
incision 
showed  carci- 
noma 


None  except 
upper  lobe 


Left  lung, 
lymph 
nodes  of 
neck  and 
chest;  liver, 
thyroid 
gland 


Left  lung, 
anterior 
mediasti- 
num, and 
left  lobe  of 
liver 


Liver,  both 
kidneys, 
dura,  brain, 
bones  of 
skull 


Pavement 
epithelium 


There  was  not 
much  dyspnoea 


Carcinoma 


Cylindrical 
cell  carci- 
noma 


Origin  from  bron- 
chial mucous  mem- 
brane 


Typical 
pavement 
epithelium 


Author  assumes  al- 
veolar epithelium  as 
origin  of  tumor 


16 


226 


TABLE   I 


329 


330 


331 


332 


333 


334 


335 


336 


Walshe,  W.  H. 

A  Practical   Treatise 
on  Diseases  of  the 
Lung,  etc.     4th  Ed. 
London, 1871 

Waters, 

Lancet,  XIX,  1871 


Wechselmann, 

Diss.  Milnchen,  1882 

(After  Passler) 
Ein  Fall  von  primarem 

Lungencarcinom 


Weinbergeb, 

Zeitsch.  f.Heilk.1901, 

II,  78 
Beitrag  zur  Klinik  der 

malignen     Lungenge 

schwtilste 


Log.  cit. 


Werner, 

Diss.  Freiberg,  1891 
(After  Passler) 

Das    primare    Lungen- 
carcinom 


Log.  cit. 


West, 

Trans.  London  Path. 

Soc.     XXXV,     1884, 

87-88 
Primary  Cancer  of  Root 

of  Right  Lung 


M 


M 


M 


M 


M 


M 


M 


Not 
stated 


Not 
stated 


64 


42 


62 


19 


65 


39 


LUNG    IN- 
VOLVED 


R 


R 


Both 


R 


R 


R 


R 


CLINICAL    SYMPTOMS 


Exclusively     psychic     symptoms. 
Neither  local  nor  systemic  symptoms 
pointing  to  lungs.     No  cough.    Dura- 
tion about  8  months 


Pain,  dyspnoea,  cough.  Swelling  and 
cyanosis  of  face,  neck,  arms,  and  chest. 
Supraclavicular  glands.  Dulness  over 
right  chest;  bronchial  breathing  above, 
diminished  or  absent  breathing  below. 
Duration  about  2  months 

No  clinical  history 


No  heredity.  Fever;  cough.  In- 
creasing dulness  over  right  apex;  to 
a  less  degree  over  left.  Diminished 
fremitus;  bronchial  respiration.  Pain, 
dysphagia,  dilated  veins.  Enlarged 
axillary  glands;  compression  of  tra- 
chea. Dyspnoea,  cedcema  of  larynx. 
CEdoema  of  face  and  arms.  Cyanosis. 
Death  after  profuse  haemoptysis.  Du- 
ration of  disease  about  one  year. 
Diagnosis  made  during  life. 


No  heredity.  Pain,  cough,  dyspnoea, 
emaciation.  Secondary  tumors  in  vari- 
ous parts  of  body.  Dulness,  dimin- 
ished and  absent  breathing  over  most 
of  right  chest.  Spleen  enlarged.  Pu- 
rulent effusion  in  right  pleura.  Dura- 
tion of  disease  about  10  months 


No  clinical  history 


No  clinical  history 


Pain,  dyspnoea,  loss  of  strength,  ema- 
ciation. Impaired  respiratory  motion 
of  right  chest.  Dulness,  faint  breath- 
ing, no  vocal  fremitus.  Left  lung  nor- 
mal. Puncture  furnishes  8  ounces 
thick  pus.  Incision  and  drainage  gives 
no  relief.  Cough  only  at  end  of  disease. 
Duration  about  4  3  months 


CARCINOMA 


227 


SPUTTTM 

AUTOPST   NOTES 

METASTASES 

MICHOSCOPE 

BEMABKS 

None 

Infiltrating  encephaloid 
cancer  throughout  right 
lower  lobe 

Left  lung 
and  brain 

No  details 

Frothy; 
later  hae- 
moptysis 

Entire  right  lung  con- 
verted into  scirrhous  tumor 
with  cavities  and  beginning 
suppuration 

Mediasti- 
nal lymph 
nodes 

No  details 

No  details 

Scirrhous  tumor  of  both 
lungs 

No  details 

Pavement 
epithelium 
proliferating 
from  periph- 
eral portions 
into  other- 
wise normal 
pulmonary 
alveoles 

Mucoid,  oc- 
casion- 
ally 

bloody, 
haemop- 
tysis. No 
tubercle 
bacilli. 
Abun- 
dant epi- 
thelial 
cells 

Carcinoma  of  right  upper 
lobe  beginning  in  a  second- 
ary bronchus  and  involving 
main  bronchus,  trachea,  left 
main  bronchus,  upper  cava, 
both  pleurae,  2d  and  3d  ribs 
and  intercostal   muscles. 
Bronchiectasis  right  middle 
lobe 

Bronchial 
and  cervical 
lymph 
nodes 

Fibrous 
stroma;     cy- 
lindrical   epi- 
thelial cells 

Tumor 
particles 
are 
found 

Carcinoma  of  right  main 
bronchus;   abscess   and  ne- 
crosis of  right  lower  lobe 

Liver,  kid- 
ney, mus- 
cles, intes- 
tines, pari- 
etal bone, 
brain 

Alveolar 
structure;  cu- 
boid epithe- 
lial cells 

No  details 

Tumor  in  right  upper  lobe 

Both  lungs, 
regionary 
lymph 
nodes,  liver, 
spleen,  kid- 
neys 

Small  cuboid 
cells 

No  details 

Tumor  size  of  walnut  in 
secondary  bronchus  and  left 
lower  lobe 

Bones 

No  details 

None 

Hard  mass  at  root  of  right 
lung   following   main   bron- 
chus which  it  compresses. 
Spreads  throughout  lung 
along  bronchial  ramifica- 
tions.    Two  abscess  cavities 

Left  lung 
and  liver 

Cancer  with 
well-devel- 
oped stroma 

228 


TABLE   I 


NO. 


337 


338 


339 


340 


341 


342 


343 


344 


Log.  git. 


WiEBER, 

Diss.  Berlin,  1889 
Primares    Lungencarci- 
nom,  etc. 


WlLLANEN, 

Zeitschr.    f.    Krebs- 
forsch.    1905,  III,  p. 
618.     Wratsch   (Rus- 
sian)  1904,  No.  44 

Zwei  Falle  von  prima- 
rem  Lungencarcinom 

Log.  cit. 


WiLLEHT, 

Diss.  Wllrzburg,  1905 
Beitrag    zur    Casuistik 
des   primaren   Lun- 
gencarcinoms 


WiTHAUEK, 

Therapeut.     Monats- 
hefte,  1899,  April,  p. 
185 
Das  primare   Lungen- 
carcinom 


Wolf, 

Fortschritt.  der  Med. 

XIII,  1895 
Der    primare    Lungen- 

krebs 


Log.  cit. 


M 


M 


Not 


M 


M 


M 


62 


49 


stated 


Not 


48 


62 


54 


57 


LUNG    IN- 
VOLVED 


R 


R 


stated 


R 


CLINICAL    SYMPTOMS 


Brother  died  of  cancer  of  liver. 
Cough,  rapid  emaciation.  Physical 
signs  like  preceding  case.  Enlarged 
supraclavicular  glands.  Diagnosis 
made  during  life.  Duration  about  10 
months 

Family  history  of  cancer.  Asthma 
and  bronchitis.  Later  pain  and  tvunor 
in  leg  which  was  amputated.  Tumor 
found  to  be  carcinoma.  Cachexia; 
cough.     Death  from  exhaustion 


Clinically  the  symptoms  of  catarrhal 
pneumonia.  Cough,  dyspnoea,  and  ca- 
chexia 


Clinical  symptoms  those  of  chronic 
consoUdation  of  the  lung.  Cough, 
dyspnoea,  and  cachexia 

No  heredity;  always  healthy. 
Cough,  increasing  debility.  Dulness 
over  left  lung;  diminished  breathing; 
some  bronchial  respiration.  No  pain, 
dyspnoea,  or  fever.  Later  paralysis  left 
hypoglossal  and  facial;  complete  left 
hemiplegia 


No  heredity.  Some  dry  cough,  but 
complains  mainly  of  stomach.  In- 
tense hunger,  but  disgust  for  food; 
occasional  vomiting.  Flatness,  in- 
creased resonance,  and  absence  of  re- 
spiratory sounds  over  right  infracla- 
vicular region.  Heart  sounds  are  heard 
with  especial  loudness  over  this  area. 
Dyspnoea,  pain  over  both  lungs,  harass- 
ing cough,  emaciation.  Slight  bulging 
of  dull  area 

The  cUnical  picture  is  that  of  chronic 
phthisis.     Nothing  to  indicate  tumor 


Clinical    history    that    of    chronic 
phthisis 


CARCINOMA 


229 


SPUTUM 

AUTOPSY    NOTES 

METASTASES 

MICEOSCOPE 

BEMABKS 

Occasion- 

Around main  bronchus  a 

Tracheal 

Scirrhus 

ally 

white  firm  tumor  penetrat- 

and cervical 

bloody 

ing  lung  following  bronchi. 
Consolidation  and  ulcerated 
cavity  at  root  of  lung 

lymph 
nodes;  liver 
and  both 
kidneys 

No  details 

Tumor  size  of  walnut  in 

Lung,  liver. 

No  details 

Author      considers 

middle  of  right  lower  lobe. 

bronchial 

the   lung   tumor   the 

Tumor  infiltration  through- 

lymph 

primary  one 

out  lower  lobe  surrounded 

nodes.  Left 

by  broncho-pneumonic  con- 

leg 

sohdation 

No  details 

Miliary  cancer  nodules 
originating   from   smaller 
bronchioles  and  alveoli 

No  details 

No  details 

No  details 

A  well-defined  tumor 

No  details 

No  details 

Occasion- 

Bloody effusion  in  left 

Mediasti- 

Gland-like 

Author  calls  tumor 

ally 

pleura.     Large  tumor  in  left 

nal,  perigas- 

arrangement; 

carcinoma  myxomat- 

bloody. 

upper  lobe;  somewhat  small- 

tric and  peri- 

principally 

odes.     Origin      prob- 

Repeated 

er   one   in   left   lower  lobe. 

aortic  lymph 

cyhndrical 

ably    bronchial    mu- 

hsemop- 

WaUs  of  bronchi  and  blood 

nodes.  Liver, 

epithelial 

cous  glands 

tyses 

vessels  infiltrated.     Mucoid 

brain,  kid- 

cells chang- 

areas in  tumor 

neys,  right 
adrenal  and 
thyroid 

ing  to  cuboid 
and  some  fiat 
polymor- 
phous forms. 
Distinct  se- 
cretion of 
mucus 

No  details 

Large  tumor  in  right  up- 
per lobe 

Both  lungs, 
liver,  and 
kidneys 

No  details 

No  details 

Tubercular  cavity  in  left 

Right 

Pavement 

lung  in  which  carcinomatous 

pleura  and 

epithelium 

tumor  proliferates 

left  inter- 
costal 
muscles 

with  typical 
cancer  pearls 

No  details 

Tubercular  cavity  in  right 
upper  lobe  containing  poly- 
poid cancerous  excrescence 
near  the  efferent  bronchus 
of  the  cavity.     Walls  of 

No  details 

Pavement 
epithelium 
with  cancer 
pearls 

230 


TABLE    I 


LUNG   IN- 
VOLVED 


345 


Log.  cit. 


M 


64 


R 


346 


Log.  git. 


M 


56 


347 


Log.  git 


M 


54 


R 


348 


Log.  cit. 


M 


44 


R 


349 


Log.  git. 


48 


R 


350 


Log.  cit. 


M 


36 


No  heredity.  Emphysema,  bronchi- 
tis, emaciation.  Pleurisy  and  pneu- 
monia of  right  lung;  after  which  dul- 
ness  remains.     Pain;    increasing  dysp- 


Signs  of  pulmonary  phthisis.  Heart 
pushed  to  left.  Sudden  death  from 
hgemorrhage 


CLINICAL   SYMPTOMS 


No  clinical  history 


Pain  in  right  chest;  cough.  Dul- 
ness  over  upper  portion  right  chest; 
feeble  respiration.  Increasing  emacia- 
tion. Left  lung  normal.  Duration 
about  2  months 


Cough,  dyspnoea;  dulness  over  right 
chest  with  diminished  respiration.  Re- 
peated aspirations:  clear  serum 


No  heredity.  Pleurisy  and  pneu- 
monia; then  dyspnoea,  night-sweats, 
and  great  cachexia.  Left  chest  more 
expanded  than  right.  Flatness  with 
slight  tympanitic  note  from  left  clavi- 
cle downward;  bronchial  respiration. 
Exploratory  puncture  negative,  but 
needle  penetrates  into  hard  mass. 
Axillary  and  infraclavicular  glands 
enlarged 


CARCINOMA 


231 


BPUTUM 

AUTOPSY    NOTES 

METASTASES 

MICROSCOPE 

REMARKS 

bronchus  thickened  and  mu- 

cous   membrane    ulcerated. 

Tubercular  granulations  all 

over  neoplasm 

Mucoid; 

Middle    and    lower    lobe 

Liver 

Fibrous 

later 

converted  into  large  tumor 

stroma;  alve- 

bloody. 

penetrating  diaphragm  and 

olar  struc- 

No tu- 

continuous  with  secondary 

ture;  flat  epi- 

bercle 

tumor  in  liver 

thelial  cells. 

bacilli  or 

Epithelial 

tumor 

pearls  in  aci- 

cells 

nous  alveoles 

Haemor- 

Tumor in  left  apex.     In 

No  details 

No  details 

rhage 

left  upper  lobe  large  cavity 
with  necrotic  walls;    left 
main  bronchus  almost  com- 
pletely destroyed  by  tumor. 
Tumor    surrounds    necrotic 
walls  of  cavity.     Miliary  tu- 
bercles over  right  pleura 

No  details 

Tumor  in  right  lower  lobe 

Bronchial 

Alveolar 

penetrating  between  7th  and 

lymph 

structure; 

8th  ribs.     Cavity  in  centre 

nodes 

small  oval 

of  tumor  surrounded  by  nod- 

epithelial 

ulated    neoplasm.       Cavity 

cells 

communicates  with  lower 

main    bronchus,    the    walls 

of   which    are  partially  de- 

stroyed by  tumor 

Yellow,    no 

Prominent  tumor  of  right 

Both 

Alveolar 

Histogenesis  not  to 

tubercle 

upper  lobe  perforating  into 

lungs 

structure; 

be  determined 

bacilli, 

right  upper  bronchus  with 

pleura,  peri- 

small oval  or 

some 

destruction  of  its  walls.  The 

cardium, 

cylindrical 

blood 

cancer  is  surrounded  by 
Fresh  miliary  tubercles. 
Both  suprarenals  are  tuber- 
cular;   tubercular    ulcer    in 
ileum 

liver 

cells 

Scant,  no 

Small  hard  nodules  at  root 

Bronchial 

Large  alveoli 

Histogenesis  not  to 

blood  or 

of  right  lung.     Polypoid  ex- 

and tracheal 

filled  with 

be  determined 

tubercle 

crescences  on  mucous  mem- 

lymph 

polymor- 

bacilli 

brane  of  larger  bronchi.     Bi- 

nodes. 

phous  small 

furcation   surrounded   by 

Pericardium 

epithelial 

large    tumors    of    bronchial 

cells.    Miliary 

and  tracheal  nodes.     Fresh 

cancer 

miliary  tuberculosis  of  both 

throughout 

[ungs 

both  lungs 

Slightly 

Irregularly  defined,  hard 

Pericar- 

Alveolar 

bloody, 

tumor  in  left  lung.     Cheesy 

dium,  left 

structure; 

but  con- 

pneumonia in  left  upper  lobe 

auricle,  left 

round  and  cu- 

tains 

ilso  several  tumor  nodules. 

ventricle 

boid  epithe- 

neither 

tubercle 

bacilli 

Tubercular  pleuritis 

and  lung 

lial  cells 

nor  tu- 

mor par- 

tides 

232 


TABLE    I 


351 


352 


353 


364 


355 


356 


357 


358 


359 


Log.  cit. 


Wolf, 
Loc.  cit. 


LOC.  CIT. 


Loc.   CIT. 


Loo.   CIT. 


Loc.  CIT. 


Loc.  CIT. 


Loc.   CIT. 


Loc.  CIT. 


SEX 

AGE 

LUNG  IN- 
VOLVED 

M 

65 

R 

M 

58 

R 

M 

42 

R 

M 

66 

L 

M 

47 

R 

M 

54 

L 

F 

54 

R 

M 

51 

R 

M 

64 

R 

CLINICAL   SYMPTOMS 


Clinical  picture  donunated  by  cer- 
ebral symptoms 


No  heredity.  Paralysis  of  left  arm 
and  leg.  Painful  swelling  of  nose  and 
epistaxis.  Dyspnoea  and  emaciation. 
Impaired  motility  of  right  chest.  Flat- 
ness right  apex;  diilness  below.  Bron- 
chial respiration.  Heart  displaced  to 
right 


Clinical  picture  dominated  by  brain 

symptoms 


Symptoms  of  cavity  in  right  chest 


Pain  in  right_  chest,  dyspnoea,  dry 
cough,    emaciation.     Dulness    over 
right  chest;  bronchial  breathing.     En- 
larged,   painful   liver;    ascites.     Some 
fever 


Anorexia,  debility,  emaciation.  Flat- 
ness over  left  chest ;  diminished  breath- 
ing; absence  of  voice.  Duration  about 
6  months 


Sudden  onset  with  chill  and  pain  in 
right  chest.  Dulness;  friction  at  right 
base;  fever.  Later  pericarditis.  In- 
creasing dyspnoea;  death.  Duration 
about   5   weeks 

No  heredity.  Acute  onset  with 
pleurisy.  After  that  emaciation  and 
cachexia.  Loss  of  patellar  reflexes; 
left  pupil  larger  than  right.  Friction 
over  right  lung.  Duration  of  disease 
about  3  months 

No  heredity.  Commenced  with  ano- 
rexia and  emaciation  followed  by 
symptoms  of  right  pulmonary  phthi- 
sis; death  after  a  few  months  without 
characteristic  symptoms 


CARCINOMA 


233 


No  details 


Glairy, 
shortly 
before 
death 
bloody, 
no  tuber- 
cle bacilli 


No  details 


No  tubercle 
bacilli 


No  details 


Mucopuru- 
lent, no 
tubercle 
bacilli ;  no 
blood 


Rusty 


No  details 


No  details 


AUTOPSY  NOTES 


Ulcerated  right  main 
bronchus  leading  into  large 
tumor  at  the  root  adherent 
to  bronchial  nodes.  Trachea 
compressed ;  bronchiectatic 
dilatations 

Retraction  of  entire  right 
lung;  dislocation  of  heart. 
Right  main  bronchus  almost 
completely  filled  with  cauli- 
flower-like tumor.  Smaller 
bronchi  of  lower  and  middle 
lobes,  same  tumor.  Tmnor 
penetrates  into  right  pul- 
monary vein  and  prolifer- 
ates into  left  auricle.  Pneu- 
monia left  lower  lobe 

Ulceration  of  right  main 
bronchus;  tumors  in  right 
upper  and  lower  lobes;  latter 
contains  cavity  perforating 
into  pleural  cavity 


Circular  obstructing  can- 
cer in  left  main  bronchus  ex 
tending  to  lower  lobe.  Cav- 
ity in  tumor 

Right  main  bronchus 
filled  with  cancer  proliferat- 
ing from  its  walls,  extending 
into  trachea.     Tumor  nod- 
ules in  right  lung 


Hard  carcinoma  of  main 
bronchus   completely   ob- 
structing it;   left  lung  re- 
tracted.    Bloody   serum   in 
abdomen;  miliary  tubercles 
in  liver 

Right  lower  lobe  and  part 
of  middle  lobe  destroyed  by 
medullary  cancer;  right  low- 
er lobe  adherent  to  pericar- 
dium 

Carcinoma    of    lower 
branch  of  right  main  bron- 
chus 


Carcinoma  of  right  main 
bronchus;  bronchiectases  in 
both  lungs 


METASTASES 


Bronchial 
lymph 
nodes;  brain 


Left  lung, 
dura  mater, 
tip  of  nose, 
nasal  sep- 
tum; right 
supraclavic- 
ular  lymph 
nodes 


Tracheal 
and  bron- 
chial lymph 
nodes,  brain, 
spleen,    kid- 
neys 

Bronchial 
lymph 
nodes  and 
liver 

Right 
pleura,  in- 
tercostal 
inuscles  and 
ribs,  verte- 
brae, liver, 
dura  mater 

Miliary  car- 
cinosis of 
peritoneum 


Lower  cava, 
right  auri- 
cle; liver 


Lung, 
spleen,  liver, 
right  pleura, 
muscles  of 
back,    brain 


Right  kid- 
ney, liver; 
spleen 


MICROSCOPE 


Pavement 
epithelium 


Adeno-carci- 
noma 


Alveolar 
structure ; 
large  poly- 
morphous 
and    cylindri- 
cal cells 

Alveolar 
structure;  cy- 
lindrical cells 


Alveolar 
structure ; 
polymor- 
phous cells 


Cylindrical 

cells 


No  details 


No  details 


No  details 


Bronchial    mucous 
glands  normal 


Histogenesis  not  to 
be  determined 


Origin  from   bron- 
chial mucous  glands 


234 


TABLE   I 


360 


361 


Loc,  CIT. 


Wolf, 
Loc.  cit. 


362 


363 


364 


365 


366 


LUNG    IN- 
VOLVED 


Loc.  CTT. 


Log.  cit. 


Loc.   CIT. 


Loc.   CIT. 


Loc.  cit. 


367 


Log.  cit. 


M 


M 


M 


M 


M 


M 


M 


57 


64 


60 


63 


64 


69 


67 


76 


R 


R 


Both 


R 


clinical  symptoms 


Pleuritic  eflfusion  in  left  chest.  As- 
piration: pus.  Resection  of  9th  left 
rib  with  removal  of  2000  c.c.  of  thick 
putrid  pus.     Death 


Aspiration  of  clear  serum  from  right 
pleura;  dulness  not  affected.  Abscess 
over  8th  rib  opened  and  rib  resected. 
Death  after  a  few  weeks 


Cough,  emaciation,  bronchitis.  Red- 
ness and  swelling  left  side  of  neck; 
fluctuating  retropharyngeal  swelling 


No   clinical  history  except  died  of 
suffocation  on  day  of  admission 


Pain,  emaciation.  Complete  dul- 
ness left  lung;  no  voice  or  breathing 
sounds  A  fluctuating  swelling  at 
angle  of  left  scapula  found  on  incision 
to  be  tumor  penetrating  from  interior 
of  chest.     No  cough 


Clinically   characteristic   of   pulmo- 
nary phthisis 


No  heredity.  Dyspnoea,  dysphagia, 
emaciation.  Pain  in  left  arm.  Upper 
left  chest  bulging.  Flatness  and  ab- 
sence of  breathing  over  left  upper  lobe 


No  heredity.     Well   until   3   weeks 
before     admission;      then     increasing 


CARCINOMA 


235 


AUTOPSY  NOTES 


METASTASES 


No  details 


Mucopuru- 
lent 


No  details 


No  details 


None 


No  details 


No  details 


No  details 


Carcinoma  of  left  main 
bronchus  and  its  ramiiica- 
tions.     Large  cavity  in  left 
lower  lobe.     Extensive 
cheesy    broncho-pneumonia 
of  right  lung 

Right  main  bronchus 
completely  filled  with  papil- 
lary growths  firmly  adherent 
to  its  walls.  Tumor  pene- 
trates into  right  lung  form- 
ing a  large  tumor  in  upper 
and  lower  lobes.  Large  ves- 
sels compressed ;  upper  cava 
perforated  and  filled  with  tu- 
mor 

Cavity  in  right  upper  lobe 
communicating   with   bron- 
chi completely  closed  by  tu 
mor  originating  from  their 
walls 


Pericar- 
dium,  Uver, 
left  kidney, 
and  right 
suprarenal 


Mediasti- 
nal lymph 
nodes;  left 
auricle,  kid- 
neys, left 
suprarenal 


MICROSCOPE 


Pavement 
epitheUum  re- 
sembling epi- 
dermis 


Left  kid-        Pavement 
ney,  3d  cer-;  epithelium 
vical  verte- 
bra with  de- 
struction  of 
bone  and 
compression 
of  cord;  also 
left  ventri- 
cle and  bron- 
chial Ijonph 
nodes 


Papillary  proliferation  Both  lungs, 
almost  completely  closing  liver,  spleen, 
lower  portion  of  trachea  andjand  left 


extending  into  both  bronchi. 
Also  large  tumor  surround- 
ing trachea  and  large  bron- 
chi and  compressing  upper 
cava 

Entire  lower  lobe  con- 
verted into  large  cavity  the 
walls  of  which  consist  of 
white  tumor.  Main  lower 
bronchus  communicates  di- 
rectly with  cavity  and  is 
obstructed  by  proliferating 
tumor 

Tumor  proliferation  in 
right  main  bronchus;  bron 
chiectatic   cavities  in  right 
lower  lobe 

Left  main  bronchus  al- 
most completely  filled  with 
tumor  which  proliferates 
from  its  walls  and  extends 
along  ramifications  into  left 
upper  lobe  forming  large 
hard,  white  tumor 

Carcinoma  of  left  main 
bronchus  and  left  lung 


kidney 


Bronchial 
lymph 
nodes  and 
lung 


Bronchial 
lymph 
nodes  and 
liver 

Bronchial 

and  retro- 
peritoneal 
lymph 
nodes;  peri- 
cardium 


No  details 


No  details 


REMARKS 


Pavement 
epithelium 


Pavement 
epithelium 


Pavement 
epithelium 


Alveolar 
structure; 


236 


TABLE   I 


368 


369 


370 


371 


372 


373 


Log.  cit. 


M 


56 


Log.  git. 


Wolf, 
Loc.  cit. 


Log.  cit. 


Loc.   CIT. 


Loc.  CIT. 


M 


M 


M 


M 


55 


47 


63 


54 


59 


LTJNG    IN- 
VOLVED 


R 


R 


Both 


CLINICAL    SYMPTOMS 


hoarseness,  pain  in  chest,  dyspnoea, 
dysphagia,  and  palpitation.  Paralysis 
of  left  recurrent.  No  signs  in  heart 
or  lungs.  Treated  for  6  months  by 
electricity  and  felt  well;  then  rapid 
failing,  dyspnoea,  effusion  in  left  pleura 

Father  died  of  cancer  of  the  stomach. 
Well  until  a  year  ago,  then  dyspnoea, 
debility,  and  emaciation.  Left  upper 
chest  retracted  and  impaired  respira- 
tory motion.  Dulness  over  left  lung 
with  loud  bronchial  breathing 


No  clinical  history 


Always  well.  Disease  commenced 
with  paralysis  of  right  vocal  cord  and 
dysphagia.  Soon  thereafter  dyspnoea 
and  a  sense  of  suffocation.  Later 
intense  tracheal  stenosis.  Hard  nod- 
ules in  thyroid  which  seem  to  extend 
up  from  below  sternum.  Dulness 
over  sternum  and  on  right  side  behind. 
Tracheotomy,  with  long  canula  intro- 
duced into  right  bronchus.  This  ia 
followed  by  putrid  bronchitis,  im- 
paired deglutition,  increasing  debility. 
Double  pleuro-pneumonia;  death 

Sudden  onset  with  anorexia,  debility, 
pain  in  lower  abdomen,  emaciation, 
icterus,  cedcema  of  skin  of  abdomen  and 
lower  extremities.  Liver  much  en- 
larged; no  nodules  can  be  felt. 
Nothing  found  in  lungs.  Duration 
of  disease  only  about  3  weeks 

Clinical  symptoms  of  pleurisy  with 
effusion 


No  heredity.  Well  until  6  months 
before  admission  when  dyspnoea,  pain 
in  chest,  cough.  On  admission  cyano- 
sis, impaired  respiratory  motion  of 
left    chest.     Dulness   from   middle   of 


CARCINOMA 


237 


Bloody,  no 
tubercle 
bacilli   or 
tumor 
cells 


No  details 


No  details 


No  details 


No  details 


Haemopty- 
sis; tuber- 
cle bacilli 


AUTOPSY    NOTES 


Left  main  bronchus  com- 
pletely obstructed  by  carci- 
noma proliferating  also  into 
trachea  and  right  bronchus. 
Greater  part  of  lung  con- 
verted into  solid  tumor 
extending  along  bronchial 
ramifications 

Carcinoma  of  right  main 
bronchus 


METASTASES 


Just  below  right  lobe  of 
thyroid  a  large  tumor  which 
penetrates  into  right  upper 
chest     adherent    to     bones 
which  are  not  affected.  Lob 
ulated  tumor  from  bifurca 
tion    extending    into    right 
main  bronchus,  penetrating 
its  walls,  and  extending  into 
surrounding   lung   tissue. 
Tumor  in  upper  lobe  in  di 
rect  contact  with  large  tu 
mor  on  thyroid 

Left  main  bronchus  and 
bronchus  from  left  upper 
lobe  obstructed  by  cancer 
Walls  of  both  bronchi  infil- 
trated 


Obstruction  of  right  main 
bronchus  by  cancer.  Sur- 
face of  right  lung  covered 
with  net  of  lymphatics  in- 
jected with  white  tumor  ma- 
terial 

Carcinoma  growing  from 
walls  of   both   bronchi   and 
trachea  and  obstructing 
their    lumen.     Continuous 
with  this  a  tumor  spreading 


Bronchial 
lymph 
nodes,   peri- 
cardium, 
heart,  thy- 
roid, and 
both  supra- 
renals 

Bronchial 
Ijonph 
nodes,  right 
lung,  liver, 
lymph  nodes 
around  por- 
tal vein, 
retroperi- 
toneal nodes 
and  bodies 
of  7th  to 
10th  dorsal 
vertebrae 

Bronchial 
lymph 
nodes 


MICROSCOPE 


Bronchial 
lymph 
nodes  and 
liver 


Bronchial 
lymph 
nodes,  right 
pleura,  peri 
cardium 


Left  auri- 
cle; oesopha- 
gus and  left 
kidney 


pavement 
epithelium 
typical  giant 
cells 


Scirrhus- 
like;  small 
round  and 
cuboid  cells 


Alveolar 
structure ; 
broad  con- 
nective tissue 
bands  of  stro- 
ma; large  and 
oval  epithelial 
cells 


No  details 


No  details 


No  details 


No  details 


Origin   from   bron- 
chial  mucous   glands 


Origin   probably 
from    bronchial    mi 
cous  glands 


238 


TABLE   I 


NO. 

AUTHOB 

SEX 

AGE 

LUNG    IN- 
VOLVED 

CLINICAL  SYMPTOMS 

374 

Z1EM88EN, 

Berlin,  klin.  Wochen- 
Bchr.  1887 

M 

50 

L 

scapula     downwards;      no     fremitus. 
Dulness  over  right    apex  with  feeble 
respiration     and     rales.    _    Aspiration 
evacuated    large    quantities    of    clear 
serum.     Death     with     symptoms     of 
progressive   tuberculosis 

Diagnosed  first  as  tuberculosis;  then 
as  syphihs.     Dulness  over  entire  left 
anterior  chest  extending  to  lateral  and 
posterior   aspects   to    below    spine    of 
scapula.     Over    this    area    bronchial 
breathing  and  dry  rales.     Bulging  of 
left  chest;    intercostal  spaces  obliter- 
ated.    All   symptoms    and    signs    dis- 
appeared   under    antisjT)hilitic    treat- 
ment;   then   reappeared;    again  shght 
improvement  under  mercury  followed 
by  rapid  failure  and  death 

CARCINO^IA 


239 


AtTTOPST    NOTES 


At  first  fi- 
brinous, 
then 
rusty 


over  both  lungs  and  into  left 
auricle.  Pulmonary  veins 
compressed.  Lesions  of  old 
and  more  recent  phthisis 


Jellj'-like  mass  at  apex  of 
left  lung:  remainder  of  left 
lung  diffusely  infiltrated 
with  carcinoma.  Large  ab- 
scess behind  sternum;  an- 
other behind  pericardium 


METASTASES 


None 


MICROSCOPE 


Carcinom- 
atous struc- 
ture 


240 


TABLE   II 


Barclay,  H.  C. 

New    Zealand    Med. 

Jour.,V,  1892, 170-172 
Sarcoma  of  Lung 


Bauman  &  Bainbridge 

Lancet,  1903,  I 
Primary  Sarcoma  of  the 

Lung 


Bell, 

Monthly  Jour.  Med 
Science,  London,  1846 

-47 


Bjornsten, 

Centralbl.  f.  Path. 

Anat.,  Vol.  15,  1904, 
..  p.  513 
Uber  Lungen  und  Herz 

geschwiilste  bei  Kin 

dern  (Swedish) 

Blumenthal, 

Diss.  Berlin,  1881 
Zwei   Falle  von    prima- 

ren  malignen  Lungen 

tumoren 


Bock,  A.  F. 

Weekly  Med.  Review, 

St.  Louis,  Vol.  XIX, 

1889,  p.  512 
Primary  Sarcoma  of  the 

Lung 


M 


M 


M 


18 


3  yrs. 
11  mos, 


28 


20 


LUNG     IN- 
VOLVED 


R 


CLINICAL    SYMPTOMS 


No  heredity.  Disease  commenced 
with  pain  at  right  base,  some  cough, 
slight  temperature.  Dulness  over 
greater  portion  of  left  chest;  absence 
of  vocal  fremitus,  some  harsh  respira- 
tion and  diminished  breathing  sounds. 
Emaciation.  Temperature  at  times 
to  104.  Gradually  bulging  over  left 
chest;  oedcema  of  left  arm  and  chest. 
Glands  above  left  clavicle.  Two  ex- 
ploratory punctures  practically  nega- 
tive.    Pain  always  at  right  base 

Well  until  6  weeks  before  admission. 
Illness  commenced  with  headache  and 
abdominal  pain;  later  emaciation, 
cough,  haemoptysis.  Flatness,  dimin- 
ished voice  and  breathing,  bulging  of 
intercostal  spaces,  displacement  of 
heart  to  right.  Fever  101.  Aspira- 
tion recovered  only  a  small  amount 
of  bloody  fluid  without  anything  char- 
acteristic.    Duration  8  weeks 

Pain  in  sternum ;  later  severe  cough, 
dyspncea,  and  vomiting.  Retraction 
of  left  chest;  imperfect  expansion,  no 
fremitus.  Dulness  over  entire  left 
lung  in  front  and  behind;  absence  of 
breathing  sounds;  numerous  rales. 
CEdoema  of  upper  and  lower  extremi- 
ties; diarrhoea.  Duration  of  disease 
about  3  years 

No  clinical  history 


For  several  years  pain  in  left  arm; 
7  months  before  admission  swelling 
on  left  chest;  later  swelling  in  left 
axilla  reaching  size  of  a  child's  head. 
No  respiratory  disturbances.  Dulness 
over  left  chest  more  in  front  than  be- 
hind, with  absence  of  breathing  sounds. 
No  cough;  no  sputum.  _  Fluctuation 
in  axillary  tumor.  Aspiration  with- 
draws a  Hght  green,  clear,  mucoid  fluid 


No  heredity.  Disease  commenced 
with  fever  and  severe  pain  in  left  side, 
the  latter  continuing  until  death. 
Fever  yielded  to  quinine  (probably 
malarial).  No  cough;  some  dyspnoea. 
Sweating  of  right  half  of  body;  left 
always  dry.  Left  thorax  larger  than 
right.  Impaired  respiratory  motion; 
enlarged    superficial    veins.      Marked 


SARCOMA 


241 


SPUTUM 

AUTOPSY    NOTES 

METASTASES 

MICROSCOPE 

REMABKS 

Scant, 
bloody 

Old  and  recent  pleuritic 
adhesions    in    right    chest. 
Effusion     in     left     pleura. 
Greater    part    of    left    lung 
replaced   by  hard,    nodular 
timior.     Smaller        bronchi 
occluded 

None 

"Small  celled 
sarcoma" 

Hffimop- 

tysia 

Upper  lobe  of  left  lung  re- 
placed by  soft  sarcomatous 
tumor.     Pleura  thickened 

None 

P 

Abundant, 
green  and 
foetid 

Lower  left  lobe  one  large 
cavity   with  hard  irregular 
walls,  filled  with  green  fluid. 
Numerous  spherical  nodules 
excavated  in  same  manner 
scattered  through  remainder 
of  left  lung  and  in  right 

None    ex- 
cept nodules 
mentioned 
in  right  lung 

None  given 

Although  no  micro- 
scopic examination  is 
given,  the  age  of  the 
patient,   sputum  and 
character  of  the  nod- 
ules   speak   for    sar- 
coma 

Not  given 

Entire  right  lung  trans- 
formed into  soft  nodular  tu- 
mor.    Large  vessels  at  heart 
surrounded  by  tumor 

Left  lung, 
pericardium 
and  heart 
muscle 

Round  celled 
sarcoma 

None 

Left  pleura  400  c.c.  bloody 
fluid.     Upper    lobe    of    left 
lung   compressed    and   flat- 
tened.    Of   the   lower   lobe 
only    a    narrow    border    of 
highly  compressed  lung  tis- 
sue   remains,    all    the    rest 
taken  up  by  a  large  tumor 
which    has    eroded    several 
ribs,   and  which  has  pene- 
trated  into  the   axilla   and 
compressed     the      brachial 
plexus 

None 

Myxosar- 
coma 

None 

Entire  left  thorax   occu- 
pied by  white  tumor  mass 
without  visible  lung  struc- 
ture.    Left     bronchus     en- 
tirely obliterated.     All  other 
organs  healthy 

None 

Large  spin- 
dle celled  sar- 
coma 

17 


242 


TABLE   I 


NO. 

AUTHOB 

SEX 

AGE 

LUNG     in- 
volved 

CLINICAL    SYMPTOMS 

emaciation.     Flatness  and  absence  c 

breathing  sounds  over  all  of  left  lung 

Heart  to  right  of  sternum.     Repeate 

aspiration  only  small  quantity  sere 

purulent  fluid.     Sudden  death  dvu-in 

aspiration.      Duration    of    disease 

months 

7 

Box,  C.  R. 

St.  Thomas  Hosp.  Re- 
ports, 1896,  p.  260 
Sarcoma  of  Lung 

M 

5 

L 

No  heredity;    good  health  until 
months  before  admission,  when  grac 
ually  increasing  lump  under  angle  c 
left  scapula.      Slight  cough,  pain,  in 
creasing  dulness  over  upper  left  ches 
Diminished      voice,      breathing      an 
fremitus.    Negative  aspiration.    Late 
dilatation  of  superficial  veins ;  enlarge 
ment  of  axillary  and  cervical  glands 
Later  dulness  and  tubular  breathin 
over    right    upper    lobe.      Occasions 
fever.  Extreme  dyspnoea  and  cyanosis 
Duration  of  disease  about  1 1  months 

8 

Bramwell,  Byron, 
Clinical  Studies,  Vol. 
I,  1903,  p.  130 

Solid    Intrathoracic 
Tumor 

M 

57 

L 

Illness  commenced  7  months  befor 
admission  with  dyspnoea  on  exertioB 
weakness,  hoarseness,  cough,  pain  i 
left  chest.    Luetic  infection  admittec 
Dulness  all  over  left  chest,  more  fla 
on    upper    part    than    base.      Lou 
bronchial  breathing  at  base,  increase 
vocal  fremitus;    no  rales.     Punctur 
negative.    Left  chest  i  inch  more  thai 
right.     Heart  not  displaced.  _   Patien 
was  treated  with   KI   and   improve 
somewhat;  gained  7J  pounds  in  weigh 
Physical  signs  remain  the  same.     Sue 
den  death 

9 

Braureuteh, 

Diss.  Miinchen,  1881 
(after  PoUak) 

Prim^res    Sarkom    der 
Lunge  und  der  Bron- 
chial driisen 

M 

56 

R 

No  clinical  history.    Admitted  un 
conscious   and   moribund;    died   afte 
5  days 

10 

Chiari, 

Wien,    1878,    No.   6 
(quoted  after  Fuchs) 

Anzeiger     der     Gesell- 
schaft  der  Arzte 

F 

14 

R 

No  clinical  history  except  that  chil 
died  of   facial  erysipelas  and  genera 
oedcema 

11 

Coats,  Joseph, 

Glasgow  Med.  Jour., 
New  Series,  Vol.  VI, 

1874,  p.  274 

Not  me 

ntioned 

No  data  except  persistent  vomitin 
and  symptoms  of  laryngeal  obstruc 
tion 

SARCOMA 


243 


AUTOPSY    NOTE8 


Nearly  the  whole  of  left 
lung  converted  into  a  soften- 
ing tumor  continuous  with 
large  external  mass.  Erosion 
of  5th  to  8th  ribs.  Large 
hard  tumor  infiltrating 
upper  and  middle  right 
lobes,  adherent  to  upper 
dorsal  vertebrae  and  infil- 
trating dura.  Cord  healthy 
All  other  viscera  healthy 


Large  new  growth  from 
root  of  lung  and  bronchial 
glands  extends  in  large 
masses  along  bronchi  into 
lung.  Left  main  bronchus 
completely  occluded,  the 
lung  collapsed  and  airless. 
Bronchiectasis  in  lower  lobe. 
Arch  of  the  aorta  completely 
surrounded  by  tumor 


Enormous  enlargement  of 
bronchial  glands  of  right  hi- 
lus  with  abscesses.  Nearly 
half  of  right  lower  lobe  con- 
verted into  sarcomatous  tu- 
rnor  proliferations  from  the 
hilus,  mostly  along  bronchial 
ramifications 

Upper  lobe  of  right  lung 
hard  and  firm;  middle  and 
lower  lobes  compressed.  In 
lower  part  right  lobe  pneu- 
monia. Section  of  upper 
lobe  could  be  completed  only 
with  a  saw,  and  showed  a 
spherical  tumor  10  cm.  in 
diameter.  In  interior  of  tu- 
mor bronchioles  could  be 
made  out 

Disease  centred  in  lymph 
nodes  at  root  of  lung  and  ex- 
tended from  there  to  glands 
of  neck,  many  as  large  as 


METASTASES      MICK08C0PE 


Right 
lung,  verte- 
brae, spinal 
dura 


Only 
bronchial 
lymph  nodes 
mentioned 


No  details 


None 


Not  men- 
tioned 


Not  given 


No  details 
given;  simply 
stated  sar- 
coma 


LjTnpho- 
sarcoma 


Spindle 
celled  sar- 
coma with 
calcification 


Lympho- 
sarcoma 


244 


TABLE   II 


12 


13 


14 


15 


16 


A  Case  of  Lympho-sar- 
coma  of  the  Bronchial 
Glands 


Cockle, 

Medical  Times  &  Gaz. 
Oct.  29,  1881,  p.  518 


Cohen    (S.    Solis)    & 

KiRKBRIDE, 

Proceedings  of  Path. 
Soc.  of  Philadelphia, 
New  Series,  Vol.  Ill, 
1900,  p.  200 
Tumor  (Sarcoma?)  of 
the  Mediastinal  and 
Bronchial  Glands; 
Metastases  in  Liver. 
Rupture  with  Fatal 
Haemorrhage 


COLOMIATTI, 

Rivista  Clinica  di  Bo' 
logna,  1879,  Gennaio 
Virch.    Jahrbuch  for 
1879,  I,  p.  267 

CURRAN, 

Lancet,    1880,   II,   p. 
258 


Da  VIES,  Arthur, 

Transactions  London 

Path.  Soc,  XL,  1889, 

p.  46 
Lymphosarcoma  of  Left 

Lung 


M 


Not 


M 


M 


44 


30 


given 


10 


18 


LUNG    IN- 
VOLVED 


R 


CLINICAL    SYMPTOMS 


Dyspnoea.  Absolute  dulness,  ab- 
sence of  voice  and  breathing  over  en- 
tire left  chest.  Heart  displaced.  La- 
ter increasing  dyspnoea  and  diarrhoea; 
then  coma,  convulsions,  and  death 


Pain  in  lower  right  chest.  Right 
pupil  larger  than  left.  Nothing  said 
about  cough,  sputum,  temperature, 
etc.  Enormously  enlarged  nodulated 
liver,  left  lobe  simulating  enlarged 
spleen.  Right  lung  expands  less  than 
left.  Irregular  areas  of  dulness  in 
lower  chest  with  diminished  breath- 
ing and  absence  of  fremitus.  Haemo- 
globin 60;  reds  4,400,000;  whites 
18,000.  Albumin  and  casts  in  urine. 
Aspiration  shows  serosanguinolent 
fluid  with  enlarged  leucocytes.  Slight 
dyspnoea,  sudden  collapse,  death 


No  data 


Blow  on  left  chest;  later  swelling  of 
that  spot  and  fever.  Puncture  nega- 
tive. Signs  of  pneumonia  over  left 
apex.  Dulness  on  both  sides  lower 
down.  Scarcely  any  respiratory  move- 
ment of  left  chest.  Copious  haemor- 
rhages. Rapid  increase  of  tumor. 
Duration  of  disease  about  5  months 

Pleurisy  a  year  and  three  quarters 
before  admission  to  hospital.  9  months 
before  admission  cough,  gradual  loss 
of  weight,  night  sweats,  dyspnoea, 
pain  in  left  chest.  Shortly  before 
admission  pain  in  right  groin.     Physi- 


SARCOMA 


245 


AUTOPSY    NOTES 


METASTASES 


MICROSCOPE 


a  hen's  egg.  Pericardium, 
both  parietal  and  visceral 
involved.  At  auricles  mus- 
cle had  been  replaced  by 
tumor  which  penetrated  in 
to  cavity  of  auricles,  both 
right  and  left.  Growth  ex- 
tended likewise  into  trachea 
bronchi,  and  lungs.  Right 
vagus  buried  in  tumor  and 
its  tissue  involved 

Bloody  serum  in  left  pleu-      Retro- 
ral  sac.     Upper  part  left        peritoneal 
pleura  and  lung  filled  with     IjTnph 
soft  tumor.     Tumor  appar-  nodes 
ently  from  hilus  along  bron 
chial  ramifications.    Left 
pulmonary  vein  obliterated 

Abdomen  contains  2,000      No  others 
c.c.  of  blood  and  large  clots  mentioned 
from  two  rents  in  Hver  cap- 
sule, which  is  enormously  dis- 
tended by  layers  of  swollen 
tumor  nodules.     Anterior 
mediastinal  glands  much  en 
larged;   tracheal  and  right 
bronchial  glands  also  en- 
larged.    Heart  and  large 
vessels  pushed  somewhat  to 
the  left.    Several  small  nod 
ules  in  left  lung,  also  in  left 
bronchial  glands.     Right 
bronchial  glands  enormously 
enlarged;   right  main  lower 
bronchus  almost  occluded  by 
tumor;  this  tumor  passes 
along  bronchial  ramifica- 
tions and  infiltrates  lower 
lobe._    Separate  timior  nod- 
ules in  right  lung. 

Right  upper  lobe  convert-    No  details 
ed  into  an  amber-colored 
gelatinous  neoplasm 


Left  lung  consisted  of  a  None 

mass  of  what  the  author 
calls  "medullary  cancer," 
which  had  eroded  7th  to  9th 
ribs  and  penetrated  chest 
wall 


Large   tumor   above   left     Liver,  ret 
clavicle;    large  mass  above  roperito- 
Poupart's  ligament  filling  up  neal  lymph- 
hollow  of  ilium  to  median      nodes;    over 
hne;  several  nodular  masses' spine  erod- 
below  this.     Left  pleural       ling  vertebra 


Round  celled 
sarcoma 


Unsatis- 
factory 


Probably  lympho- 
sarcoma, possibly 
from  bronchial  glands 


Spindle 
cells  and  pe- 
culiar form  of 
giant  cells 


No  details 


Original  not  acces- 
sible.    I.  A. 


Probably  sarcoma 


Round  celled 
lympho-sar- 
coma 


246 


TABLE   II 


LXJNG     IN- 
VOLVED 


CLINICAL    SYMPTOMS 


17 


18 


19 


20 


21 


Demange, 

Revue  Med.  de  I'Est, 

IV,  119 

(Quoted  by  Fuchs) 


De  Renzi, 

Giorn.    Internaz.    de 

See.     Med.     Napoli, 

1885 
Sarcoma    primario    del 

Polmone 

Dick,  J.  A. 

Australian  Med.Gaz., 
Vol.  XV,  1896,  p.  50 

Notes    in    a    Case    of 
Primary  Malignant 
Disease  of  the  Lung 


Duckworth, 

British    Med.    Jour., 

1885,  I,  943 
Malignant    Disease    of 

the  Lung 

Elkan,  Julius, 
..  Diss.  Mlinch.,  1903 
Uber  primare  Sar- 
kome  der  Lunge  im 
Anschluss  an  einen 
Fall  von  primarem 
Sarkom  der  linken 
Lunge 


M 


37 


M 


40 


40 


R 


R 


M 


M 


62 


57 


cal  signs  were  those  of  commencing 

phthisis  with  rapid  consolidation  with 
cavity  at  left  apex.  In  the  course 
of  3  weeks  cavity  disappeared  and 
complete  dulness  with  loss  of  voice 
and  breathing  sounds  took  its  place. 
Heart  pushed  to  right  side.  Large 
neoplasm  appeared  in  right  groin  and 
eventually  smaller  growths  above  left 
clavicle.  Duration  of  disease  at  least 
15  months;  probably  longer 

For  5  months  increasing  debility 
and  emaciation.  Pain  in  right  chest; 
dulness  over  left  chest  with  absence 
of  breathing.  Heart  dislocated  to 
right.  Later  cedcsma  of  left  chest, 
enlargement  of  liver,  dyspnoea  and 
cough.  Exploratory  puncture  nega- 
tive;   sudden  death 

Pain  in  right  chest  and  hypochon- 
drium;  headache,  epistaxis;  swollen 
glands  in  neck 


Symptoms  of  pleurisy  with  effusion 
of  right  side;  3  months  later  puffy 
swelling  of  face  and  neck;  slight 
cyanosis;  dilatation  of  veins  over 
right  chest;  orthopnoea;  impairment 
of  respiratory  motion.  Absolute  dul- 
ness over  right  chest  in  front  and 
behind  except  small  area  over  apex. 
Absence  of  voice  and  breathing;  every- 
thing else  normal.  Death  4  months 
after  first  examination 


Incomplete  left  hemiplegia;  cough; 
flatness  below  4th  rib  with  absence 
of  voice  and  breathing.  Purulent 
fluid  in  pleura;    pain  in  right  chest 


For  some  time  cough  and  bloody 
sputum,  then  swelling  of  hands  and 
feet;  slight  rise  of  temperature  for 
weeks;  some  loss  of  strength  and 
dyspnoea.  At  first  examination  lungs 
found  normal  except  some  dry  rales 
at  about  3rd  left  rib  anteriorly. 
Systolic  murmur  at  apex  of  heart. 
History  of  syphilis.  Clinical  diag- 
nosis at  that  time  bronchitis  with 
myocarditis.  Temporary  improve- 
ment. X-ray  showed  a  dense  shadow 
over  whole  of  left  upper  lobe.  Supra- 
clavicular glands  enlarged.  Diagnosis 
of  tumor  made  principally  by  X-ray 
picture.  Duration  of  disease  about 
10  months 


SARCOMA 


247 


AUTOPSY   NOTES 


cavity  completely  obliter- 
ated and  the  whole  left  chest 
filled  with  hard  new  growth; 
hardly  any  lung  substance 
visible.  Neoplasm  pene- 
trates diaphragm  into  abdo- 
minal cavity.  Nothing  on 
right  lung 


6  to  8  encapsulated  timaors 
from  the  size  of  a  pigeon's 
egg  to  that  of  a  fist  in  left 
lung.     No  bronchi  could  be 
traced  in  them.     Left  main 
bronchus  completely  filled 
with  tumor.     Thrombosis 
of  pulmonary  artery 

Round  celled  sarcoma  of 
right  lung  compressing  right 
bronchus 


METASTASES 


and  involv- 
ing pan- 
creas; right 
iliac  bone 
and  lymph 
nodes 


None 


MICROSCOPE 


No  details 


Clear  serum  in  right  No  others 

pleura.     Neoplasm   at  root 
of  right  lung  pressing  on 
venae  cavae  and  right  auricle. 
Right  lung  reduced  in  size; 
neoplasm  extending  along 
bronchial  ramifications 
throughout  right  lung. 
Growth  surrounds  right 
main  bronchus  and  involves 
bronchial  glands.     Bron- 
chiectatic  cavity  in  lung 

Neoplasm  from  root  of  Various 

right  lung,  proliferating  parts  of 

along  bronchial  ramifica-  brain,  liver, 

tions  and  invading  right  pancreas 
lung 

Bloody  serum  in  left 
pleura.     Large  encapsu- 
lated greenish  tumor  in  left 
upper  lobe 


Nodules 
on  pleura; 
tumor  infil- 
tration of 
2nd,  3rd 
and  4th  ribs 


Fasciculated 
sarcoma 


Round 
celled  sar- 
coma 


Mixed, 
round  and 
spindle 
celled 
sarcoma 


Diagnosis  of  tumor 
made  during  life. 

Author  believes  tu- 
mor to  have  origi- 
nated in  lung  tissue 
itself 


Round 

celled  sar- 
coma 


Medullary 
spindle 
celled  aar- 


248 


TABLE   II 


22 


23 


Faerell, 

Maritime  Med.  News 

Halifax,  XIII,    1901, 

p.  291 
Lympho-sarcoma  of 

Lung 


24 


Fbhband, 

Sarcoma  primitif  du 
Poiimon  gauche 
(after  Chauvain) 


FiNLET, 

Medical  Times  and 
Gazette,  London, 
1885,  Vol.  I,  p.  145 
Case  of  Lympho-sarco- 
ma of  Left  Lung  vnth 
great  displacement  of 
Heart 


25 


26 


M 


LUNG     IN- 
VOLVED 


Not 
stated 


32 


FOOTE,  A.  W. 

Proceedings     Dublin 

Path.     Soc,     Session 

1871-2 
Primary    Encephaloid 

Sarcoma  of  Lung 


Fraseb, 

Edinburgh  Med.  Jour 
1880  - 1881,  XXVI, 
677-673 


M 


32 


56 


39 


CLINICAL    SYMPTOMS 


Soldier;  complained  of  pain  in  neck 
and  shoulders  for  9  to  10  months,  also 
in  left  chest.  Loss  of  flesh,  short 
breath  on  exertion.  On  admission 
complete  flatness  over  left  lung  in 
front  from  4th  rib  down;  absence 
of  breathing  and  fremitus.  Pos- 
teriorly flatness  from  spine  of  scapula 
down;  loss  of  voice  and  breathing. 
Slight  dullness  and  absence  of  breath- 
ing at  right  base.  Heart  displaced 
to  right.  Diagnosis:  pleurisy.  Aspi- 
ration: "dark  fluid."  Death  6  days 
after  admission 

111  for  about  a  year  before  admission 
to  hospital,  but  nevertheless  gives 
birth  to  a  normal  chUd.  Pain  in 
chest;  dulness  to  about  middle  of 
left  lung;  abolished  breathing ;  harass- 
ing cough;  bulging  of  chest,  respira- 
tory immobility ;  displacement  _  of 
heart.  No  fever,  but  emaciation. 
Enlarged  axillary  glands.  Diagnosis 
made  during  life 

No  heredity.  For  3  years  before 
admission  failing  strength  and  pain 
in  epigastrium  and  lower  part  of 
sternum.  Cough,  emaciation,  dysp- 
noea. Lies  on  back  and  left  side  and 
any  attempt  to  change  position  brings 
on  cough  and  suffocation.  Tumor 
below  clavicle  extending  towards 
axilla;  similar  smaller  mass  above 
clavicle,  and  a  large  irregular  mass 
from  left  interspace  to  breast.  Left 
chest  larger  than  right  and  immobile 
on  respiration.  Nearly  all  of  left 
chest  in  front  and  behind  revealed 
absence  of  breathing  and  absolute  flat- 
ness. Heart  displaced  far  over  to 
right.  (Edcema  of  face,  left  arm,  and 
chest.     Duration  about  3i  years 

Sick  for  3  months  before  going  to 
hospital.  Dyspnoea  and  a  sensation 
of  weight  across  chest.  Left  chest 
gave  all  the  signs  of  pleuritic  effusion, 
chronic  and  receding.  Slight  con- 
traction of  that  side  of  chest.  _  Heart 
not  displaced.  Intense  pericardial 
friction.  No  enlarged  glands,  no 
pain,  no  haemoptysis;  much  cachexia. 
Death  from  hemiplegia  7  weeks  after 
admission 

Pain  in  right  hip  and  right  shoulder. 
Dyspnoea  and  cough.  Effusion  in  left 
pleura.  Bronchitis ;  dilatation  of  veins 
over  left  chest.  Secondary  tumors 
around  left  clavicle  and  right  humerus 


SARCOMA 


249 


AUTOPSY    NOTES 


METASTASES 


MICKOSCOPE 


No  tubercle 
bacilli 


Bloody;  hae- 
moptysis 


None 


No  details 


Copious, 
often 
bloody 


Entire  left  lung  except 
small  portion  of  apex  occu- 
pied by  large  fibrous  mass, 
involving  and  adhering  to 
pericardium  and  heart  and 
invading  left  auricle  and 
pleura.  Right  lung  normal 
except  some  pleurisy  at  base 


Entire  left  lung  occupied 
by  tumor 


Hard  nod- 
ule  in  left 
ventricle 
and  second 
ary  growth 
involving 
nearly  |  of 
left  auricle. 
No  other 
metastases 


None,  not 
even  in 
pleura 


Simply 
stated : 
lympho- 
sarcoma 


Remarkable  that 
the  man  performed 
his  duties  as  a  soldier 
until  5  or  6  days  be- 
fore his  death 


Spindle  celled 
sarcoma 


Heart  and  pericardium 
firmly  adherent.  Neoplasm 
filling  almost  entire  left 
chest.  Tumor  on  surface  of 
chest  communicates  directly 
with  tumor  of  lung.  Bron- 
chiectatic  cavities  and  ( 
eluded  bronchi 


Bronchial, 
mediastinal, 
axillary 
lymph 
nodes,  liver 


Lympho- 
sarcoma 


Entire  left  lung  infiltrated 
with  neoplasm,  bounded  by 
a  mass  of  compressed  lung 
tissue.  Only  tube  through 
mass  is  pulmonary  artery, 
which  is  much  compressed; 
bronchi  and  pulmonary 
veins  not  distinguishable 


Left  lung  entirely  solid; 
large  tumor  in  centre  reach- 
ing surface  at  3rd  and  4th 
ribs  posteriorly 


None 


Round  celled 
sarcoma 


Bronchial 
and  cervical 
lymph 
nodes,  left 
shoulder, 
right  hu- 
merus, right 
hip 


Small  round 
celled  sar- 
coma 


250 


TABLE   II 


27 


28 


29 


30 


31 


32 


33 


34 


FUCHS, 

Diss.  Miinchen 
Beitrage  zur  Kenntniss 
der     primaren     Ge- 
schwulstbildungen  in 
der  Lunge 

Log.  git. 


Log.  git. 


Hagenbach, 

1882 
(after  Roth) 


M 


M 


M 


BLlhbis, 

St.    Bartholomew's 
Hosp.    Reports,    Vol. 
28,  1892,  p.  73 
Intrathoracic  Growths 


Loc.  CIT. 


Log.  git. 


Log.  git. 


M 


M 


M 


70 


73 


74 


LUNG     IN- 
VOLVED 

R 


lOJ  yrs, 


24 


53 


36 


48 


R 


CLINICAL    SYMPTOMS 


No  cUnical  history 


Marked  cachexia;  senile  bronchitis; 
some  vomiting  after  deglutition  which 
improves.  Death  without  symptoms 
pointing  to  lungs 

Clinical  symptoms  mainly  cerebral 
and  psychic;  with  the  exception  of 
some  emphysema  nothing  abnormal 
found  in  lungs 


Treated  for  right  pleurisy  for  about 
7  weeks;  diagnosed  later  as  encap- 
sulated empyema  of  right  upper  lobe 
increasing  in  extent.  Increasing 
dyspncea;  cyanosis.  Absolute  flat- 
ness over  right  apex  in  front  to  3rd 
rib;  behind  to  angle  of  scapula.  No 
fremitus,  diminished  respiration,  sibi- 
lant rales.  Right  cla\'icle  protrudes, 
as  also  supraclavicular  space,  where 
there  is  absolute  flatness.  3  proba- 
tory punctures  in  region  of  flatness 
draw  blood  but  no  pus.  Diagnosis  of 
tumor  of  right  upper  lobe  made  dur- 
ing life 

Cough,  pain  in  right  shoulder, 
dyspnoea.  Left  chest  more  promi- 
nent; deficient  respiratory  move- 
ment; diminished  vocal  resonance; 
bronchial  respiration.  Complete  flat- 
ness of  entire  left  chest  extending 
over  sternum  to  right.  Four  tap- 
pings without  relief.  Duration  about 
6  months 

Pain,  weakness,  cough.  Dulnesa 
at  right  apex;  impaired  resonance 
over  whole  of  right  chest;  diminished 
voice  and  breathing;  some  rales. 
Duration  about  4  months 

Pain  both  sides  of  chest;  cough, 
slight  hsemoptysis.  Flatness  of  left 
chest;  absence  of  voice  and  breath- 
ing.    Duration   about   3   months 


Cough,  pain  in  left  side,  swelUng 
of  abdomen.  Absolute  flatness  with 
absence  of  voice  and  breathing  over 
entire  left  chest.  Duration  about 
10  months 


SARCOMA 


251 


AUTOPSY    NOTES 


METASTASES 


MICROSCOPE 


No  details 


None 


None 


No  details 


Scant 


Scant, 
muco- 
purulent; 
no  blood 


Scant, 
slight  hae- 
moptysis 


Scant,  no 
hsemop- 
tysis 


Primary  sarcoma  with 
central  softening  in  right 
upper  lobe. 


Nodulated  tumor  size  of 
a    child's  head   enclosed 
thick  fibrous  capsule,  in 
right  lower  lobe 

Nodule  size  of  a  pea  in 
left  upper  lobe 


Medullary  sarcoma  of 
right  upper  lobe  extending 
to  ribs  and  vertebrae.  Tu 
mor  size  of  child's  head  dis 
places  right  subclavian  art- 
ery upward,  right  bronchus 
downward 


Bronchial 
lymph 
nodes,  liver, 
pancreas 


Nodule  in 
left  lower 
lobe 


None 


Pleura 


Not  given 


Spindle 
celled  sar- 
coma 


Structure 
in  some  parts 
Ismapho-sar- 
coma,  in 
others  fibro- 
sarcoma 

Round  celled 
sarcoma 


Left  lung  infiltrated  by 
soft  neoplasm  involving 
bronchial  lymph  nodes,  oeso- 
phagus, and  destrojdng  and 
obliterating  left  main  bron- 
chus 


Upper  right  lobe  com 
pletely  infiltrated  with  neo- 
plasm, white,  firm  and  solid 
in  upper  portion;  soft  and 
decomposed  in  lower  portion 

Upper  lobe  of  left  lung 
almost  entirely  occupied  by 
new  growth ;  lower  lobe  com 
pletely  invaded  by  tumor 


Lower  lobe  of  left  lung 
completely  occupied  by 
hard,  white  tumor.  Pleura 
enormously  thickened  and 
honeycombed 


Regionary 
lymph 
nodes,  lung, 
pericardium 


Small 
nodules  in 
right  lung, 
no  others 


Right  lung, 
bronchial 
and  medias- 
tinal lymph 
nodes 

Liver, 
spleen,  pan- 
creas, peri- 
toneum, 
and  retro- 
peritoneal 
glands 


Sarcoma 


Small  round 
celled  fibro- 
sarcoma 


Round  and 
spindle  celled 
sarcoma  with 
excessive  fi- 
brous tissue 

Sarcoma 


252 


TABLE   II 


35 


36 


37 


38 


39 


40 


Hellendall, 

Zeitschr.  f .  Klin.  Med. 

XXXVII,     1899,    p. 

435 
Ein   Beitrag  zur  Diag- 

nostik    der    Lungen- 

geschwiilste 


HiLDEBHAND, 

Diss.  BerHn,  1887 
(after  PoUak) 
Primares    rundzellen 
Sarkom     der     linken 
Lunge  im   Anschluss 
a  n     Lungentuberku- 
lose 


Hooper, 

Intercolonial  Med. 
Jour,  of  Australasia, 
Vol.  Ill,  1898,  p.  222 

Sarcoma  of  Lung 


Iscovesco, 

Bull,  de  la  Soc.  Anat 

de    Paris,     1888,    p 

182 
Sarcome  pulmonaire 

simulant  la  Phthisie 


JAN38EN, 

Diss.  Berlin,  1879 
Ein   Fall  von  Lungen- 
sarkom     mit     grass- 
griinem  Auswurf 


KOBYLINSKI, 

..  Diss.  Greifswald,  1904 
Uber     primare     Sar- 
kome  in  der  Lunge 


M 


M 


M 


M 


47 


46 


24 


Not 
stated 


30 


20 


LUNG     IN- 
VOLVED 


R 


R 


R 


Both 


CLINICAL    SYMPTOMS 


No  heredity;  dry  cough,  dyspnoea; 
pain  in  chest.  Increasing  dulness 
from  right  apex  downward.  Varying 
physical  signs.  Later  cedcEma  of  legs 
and  right  arm.  Dyspncsa  dysphagia, 
ascites.  Dilated  superficial  veins. 
Large  hard  liver.  Bloody  effusion  in 
right  chest.  CHnical  diagnosis  at  first 
tuberculosis,  but  examination  of  white 
particles  in  bloody  effusion  showed 
heaps  of  round  cells  from  which  the 
diagnosis  of  sarcoma  of  lung  was  made. 
Duration  of  disease  about  6  years 

Acute  onset  with  pneumonic  symp- 
toms; since  then  emaciation,  dizzi- 
ness, cough;  severe  dyspnoea.  Dura- 
tion of  disease  about  1  year 


No  heredity;  always  well;  disease 
commences  with  area  of  dry  pleurisy. 
Fever  to  102,  persistent  dry  cough; 
great  debility,  dyspnoea.  2700  c.c. 
clear  serum  removed  by  aspiration 
from  right  chest.  Area  of  dulness 
anteriorly  over  middle  of  right  lung 
with  normal  breathing  and  voice 
sounds.  Tumor  was  diagnosed  from 
sweating,  cough,  emaciation.  CEdcema 
of  right  face,  chest,  and  arm.  Death 
from  asphyxia.  Duration  about  6 
weeks 

No  heredity.  Pain  in  right  chest; 
much  cough.  Signs  of  consolidation 
of  left  apex  and  patient  went  through 
all  the  clinical  stages  of  phthisis  — 
night  sweats,  haemoptysis,  some 
cedcema  of  face;   slight  albuminuria 


No  heredity.  History  of  lues. 
Pain  in  right  chest,  dyspnoea,  cachexia 
Later  painful  enlargement  of  inguinal 
glands.  Attack  of  pneumonia  with 
crisis.  After  this  progressive  dulness 
with  friction  sounds,  some  of  which 
also  appeared  on  left  chest.  Antisyphi- 
litic  treatment  shows  apparent  im- 
provement; nevertheless  dulness  in- 
creases and  cachexia  progresses. 
Duration  a  little  over  1  year 


No  heredity.  8  weeks  ago  attack 
of  scarlet  fever.  2  weeks  ago  sud- 
denly cough,  pain  in  chest.  Slight 
paralysis  first  of  foot,  then  ascending. 
6   days   before   admission  last  volun- 


SARCOMA 


253 


SPUTUM 

AUTOPSY    NOTES 

METASTASES 

MICROSCOPE 

EEMABKS 

Occasion- 

Large tumor  in  right  lung 

Only  in 

Typical 

ally 

covered      with      thickened 

liver,  no 

round  celled 

bloody, 

pleura.     Lung   compressed, 

others 

sarcoma 

contains 

in  parts  cystic 

no  tuber- 

cle bacilli, 

several 

abundant 

hsemop- 

tysea 

Mucoid, 

Pulmonary  phthisis.    Ex- 

Absolutely 

Small 

numerous 

tensive  sarcomatous  prolif- 

none 

round  celled 

tubercle 

eration  in  left  main  bron- 

sarcoma in- 

bacilli 

chus  with  ulceration  of  bron- 
chial wall.     Large  nodular, 
hard    tumor    at    left    hilus 
compressing  right  and  left 
main  bronchus 

vading  a 
previously 
tubercular 
lung.     Origin 
not  to  be  de- 
termined 

Bloody;   no 

Right  pleural  cavity  oblit- 

None 

No  details 

The  rapidity  of  de- 

tumor ele- 

erated.    Whole    right    lung 

given 

velopment    in      this 

ments;  no 

infiltrated  with  new  growth. 

case    is    remarkable. 

tubercle 

soft     and     whitish — "evi- 

Hooper   had    known 

bacilli 

dently    a    rapidly    growing 
round  celled  sarcoma" 

the   patient  well   for 
10  years.     Death  en- 
sued    in     6      weeks 
from  time  of  onset 

Scant,  hae- 

Two large  tubercular  cav- 

Right 

Not  given 

Some  doubt  as  to 

moptysis, 

ities  in  right  lung;  sarcoma- 

kidney and 

primary    site    of    tu- 

nothing 

tous  nodules  in  right  pleura. 

cEBophagus 

mor.     Possibly  pri- 

said 

Right  lower  lobe  sarcoma- 

mary in  kidney 

about 

tous  infiltration.    Tubercles 

tubercle 

in  left  lung 

bacilU 

Grass  green 

Right  lung  filled  with  con- 

Mediastinal 

Round 

color 

necting  tumor  nodules.    Tu- 

and bron- 

celled sar- 

mor in  middle  of  otherwise 

chial  lymph 

coma 

normal  left  lung.     Abscess 

nodes. 

anterior   mediastinum  over 

spleen,  pan- 

trachea 

creas,  hilus 
of  both  kid- 
neys, retro- 
peritoneal, 
axillary  and 
inguinal 
lymph  nodes 

Mucopuru- 

Left lung  adherent;  clear 

Spinal  cord 

Spindle 

lent,  no 

serum  in  pericardium. 

celled  sar- 

tubercle 

Large  solid  tumor  size  of  a 

coma 

bacilli. 

man's  head  in  left  lower  lobe 

no  blood 

almost     entirely     replacing 

254 


TABLE   II 


41 


42 


43 


44 


Krienitz,  Walter 
Diss.  HaUe,  1903 
Adenoma  der  Lunge 


Keoniq, 

Berlin  klin.  Wochen- 

schr.,  1887,  p.  964 
Ein  Fall  von  primarem 

Sarkom    der    rechten 

Lunge 


Lanqe,  J.  C. 

Penna.  Med.  Jour., 
Pittsburg,  1903-4, 
Vol.  XXXIII,  p.  202 

Four  Cases  of  Malig- 
nant Disease  of  the 
Lunga 


Loo.  CIT. 


M 


M 


M 


18 


26 


72 


12 


LUNG     IN- 
VOLVED 


R 


CLINICAL    SYMPTOMS 


tary  urination;  5  days  before,  last 
fascal  movement;  within  last  few  days 
paralysis  up  to  horizontal  mammillary 
line.  No  sensation  in  paralyzed  parts; 
no  oedcBma;  no  glands.  Dulnesa  with 
absent  breathing  over  greater  part  of 
left  chest  behind.  Some  pleuritic 
friction;  bronchial  respiration  anteri- 
orly. Heart  displaced  to  right.  Pro- 
batory aspiration  some  turbid  bloody 
fluid.  Haematuria.  Fluid  in  chest 
present  only  in  thin  layers;  most  of 
the  dulness  due  to  solid  mass  in  lung. 
Duration  a  little  more  than  1  month 

Pain  in  chest,  increasing  dyspnoea, 
palpitation.  Flatness  over  whole  of 
left  chest.     Heart  displaced  to  right 


Pain  in  right  chest.  Dulness  below 
right  clavicle;  diminished  voice  and 
almost  absent  breathing  sounds.  Clini- 
cal diagnosis  of  lympho-sarcoma  made 
from  particle  of  tissue  withdrawn  by 
needle  at  time  of  puncture.  Later 
fever,  increasing  dulness  and  disloca- 
tion of  heart,  enlargement  of  liver; 
dyspnoea;  swelling  of  cervical  and 
mediastinal  glands;  tremendous  sweat- 
ing, especially  on  right  side.  Duration 
of  disease  about  10  weeks 

Progressive  loss  of  strength  and  gen- 
eral malaise  without  definite  symptoms 
for  some  months;  then  pleuritic  pain  in 
left  chest,  some  fever;  violent  cough. 
Flatness  over  left  lower  lobe.  Aspira- 
tion negative.  No  glandular  enlarge- 
ment ;  no  cedcema.  Death  from  exhaus- 
tion 3  months  after  first  clinical  signs 

No  clinical  history.  Came  to  hos- 
pital with  incision  in  7th  left  inter- 
costal space  in  front.  Left  face,  arm, 
neck,  and  chest  oedoematous.  Dilated 
veins;  enlarged  glands.  Flatness  over 
left  chest.  Much  pain.  When  flap 
including  2  ribs  was  lifted  up  a  large 
sarcoma  was  revealed 


SARCOMA 


255 


No  details 


lung  tissue.  Involves  cos- 
tal pleura  and  penetrates  in- 
tercostal muscles;  involves 
also  lower  part  upper  lobe. 
Tumor  penetrates  through 
vertebral  column  and  fills 
canal  from  4th  to  6th  verte- 
bra. Does  not  penetrate 
dura,  but  compresses  cord. 
Above  and  below  compres- 
sion extensive  softening  of 
medulla  spinalis 


Large  tumor  weighing  20 
kilos  filling  whole  of  left 
chest  and  extending  to  right, 
pushing  heart  to  axillary 
line.  Left  lung  compressed 
to  small  strip  between  tumor 
and  chest  wall.  On  section 
soft  white  tumor  tissue  con- 
taining numerous  cystic  _ 
cavities  and  areas  of  ossify- 
ing and  ossified  tissue 


No  blood, 
no  tuber 
cle  bacilli, 
no  elastic 
fibres 


Scant, 
mucoid 


No  details 


AUTOPSY  NOTES 


METASTASES 


Large  tumor  in  anterior 
mediastinum  continuous 
with  tumor  of  right  lung. 
Tumor  affects  several  large 
bronchi.     In  upper  right 
lobe  a  fresh  pnevunonia 


"Encapsulated  fibro-sar- 
coma  in  left  lower  lobe"  as 
large  as  a  small  cocoanut. 
Small  abscess  around  tumor 


No  details 


Enormous 
masses  of  fi- 
brous tissue 
in  some  pla- 
ces having 
the  charac 
ter  of  soft 
medullary 
sarcoma. 
Areas  of  hy- 
aline carti- 
lage.    The 
small  cysts 
have  a  glan- 
dular char- 
acter, lined 
with  cylin- 
drical cells 

Right  ax 
illary  lymph 
nodes,  liver, 
cervical,  su- 
pra- and  in- 
fraclavicu- 
lar glands 
with  pres- 
sure on  vag' 
us  and  sym^ 
pathetic 


None 


MICBOSCOPE 


Fibro-chon- 
dro-adenoma 
with  sarcoma- 
tous degener- 
ation 


Sarcoma-car- 
cinomatodes 


No  details 


No  details 


No  details 


256 


TABLE   II 


45 


46 


47 


48 


49 


Lehndohff, 

Wiener  med.Wochen. 

1909,  No.  31  &  32 
Primares      Lungensar- 

kom  in  Kiudesalter 


Lenhahtz, 

Miinch.  Med.  Woch. 
1896 

Primary  Sarcoma  of 
Lung  with  Metas- 
tases in  Left  Motor 
Region 

Levit, 

Diss.  Erlangen,  1901 
(after  Pollak) 

Primares  Rundzellen 
sarkom  der  linken 
Lunge  mit  Obtura- 
tion von  grossen 
Bronchien  und  Bron- 
chiectasen 

Log.  cit. 


Mac  Donnell, 

New   York    Jour,    of 

Med..    Sept.,    1850, 

153-157 
Extensive    Encephaloid 

Disease  of  Left  Lung 


M 


Not 


46 


Not 

stated 

(adult) 


stated 


17 


LTJNQS  IN- 
VOLVED 


R 


CLINICAL  STMPTONS 


No  heredity.  Sudden  cough  and 
high  fever  for  about  8  weeks.  Bron- 
choscopy and  pumping  out  of  left 
lung;  child  worse  after  it.  Pain, 
dyspnoea,  high  fever,  harassing  cough. 
Puncture  in  left  axilla,  much  blood; 
2nd  puncture  in  front  near  sternum, 
same  result.  Some  temporary  im- 
provement. On  admission  to  hos- 
pital cyanosis,  no  fever,  left  thorax 
more  voluminous  than  right,  lags  in 
respiration;  flatness  over  all  of  left 
chest  in  front  and  behind  to  about 
7th  rib  with  sharp  boundary.  Right 
lung  normal.  Notwithstanding  the 
absolute  flatness,  respiration  much 
diminished  and  some  vocal  fremitus 
is  heard  all  over  the  flat  portion.  No 
glands;  other  organs  normal.  Increas- 
ing signs  of  compression  —  intense  dysp- 
noea, cough,  cedcema,  dilated  veins. 
No  dysphagia.  Haemoglobin  65-70; 
reds  4,820,000;  whites  16,000.  Poly- 
nuclears  70.4%.  X-ray  shows  tumor 
convex  boundary  at  base  and 
erosion  of  6th  rib.  Another  punc- 
ture of  tumor  brings  out  blood  and  a 
piece  of  tissue  from  which  the  diag- 
nosis of  round  cell  sarcoma  was  made. 
Death  after  about  5  months  of  sick- 
ness 

Cerebral  symptoms  prominent. 
Flatness  right  middle  and  lower  lobes. 
Hoemorrhagic  fluid  in  right  chest 


No  clinical  history 


No  clinical  history 


For  2  years  pain  in  left  side  and 
left  shoulder;  dyspnoea.  Later  small 
tumor  above  left  clavicle;  ptosis  of 
left  eyelid  and  contraction  left  pupil. 
Dry  cough,  emaciation,  paralysis  of 
left  arm,  oedcema  left  arm  and  chest, 


SARCOMA 


257 


AUTOPSY   NOTES 


Left  lung  entirely  com 
pressed  and  pushed  down- 
ward and  backward.  Sar- 
coma originating  from  tip  of 
left  lower  lobe,  compressing 
lung  and  displacing  heart 
and  mediastinum  to  right. 
Tumor  is  encapsulated  and 
centre  degenerated  and  ne- 
crotic.    Erosion  of  6th  rib 


No  details 


At  hilus  of  left  lower  lobe 
an  irregular  grayish  red  nod- 
ulated mass.     Pleura  over 
2  c.c.  thick,  containing  nu- 
merous abscesses.     The  tu- 
mor is  found  loosely  adher- 
ent to  the  walls  of  many 
smaller  and  larger  bronchi 
and  bronchiectases 

Large  soft  sarcoma  of  left 
hilus.  Numerous  nodules 
throughout  lung.  Prolifer- 
ation into  pulmonary  veins, 
obstructing  them.  Tumor 
fills  and  obstructs  numerous 
bronchi 

Nothing  left  of  lung  ex- 
cept thin  layer  of  lung  tissue 
at  diaphragmatic  portion  of 
tumor 


18 


METASTASES 


None,  not 
even  re- 
gional 
glands 


No  details 


No  details 


No  details 


Nodules  in 
right  lung, 
other  organs 
healthy 


MICROSCOPE 


Small 
round  celled 
sarcoma, 
probably 
congenital 


No  details 


Small 
round  celled 
sarcoma 


Round  celled 
sarcoma 


Not  given 


Origin   not   to    be 
determined 


258 


TABLE   II 


60 


61 


62 


53 


attended  by  Unusual 
Symptoms 


Mac  Donnbll, 

The  Canada  Medical 
Record.  XVI,.  No.  1, 
1887,  p.  3 

Gaillards  Med.  Jour., 
Vol.  XLVI,  Dec.  to 
June,  1888,  p.  540- 
543 
Malignant  Disease  of 
the  Lung 


Maeini, 

Giorn.  Internaz.  della 
Scien.  Med.  Napoli, 
1891,  XII,  1890.  p.  98 

Sarcoma    primitive  del 
Polmone 


McCall  Anderson, 
Glasgow    Med.   Jour. 
1893,  XXXIX,  p.  243 

Cilinical  Memoranda. 
Left  Hemiplegia  Com 
plicating  Tumor  at 
Root  of  the  Lung 


Meter, 

Diss.  Milnchen,  1900 
Beitrag    zur    Casuistik 

der     primaren     Lun- 

gensarcome 


M 


M 


M 


M 


40 


48 


54 


LUNG     IN- 
VOLVED 


R 


R 


CLINICAL    SYMPTOMS 


obliteration  intercostal  spaces,  respi- 
ratory immobility.  Dulness  over  en- 
tire left  chest  in  front  and  behind 
with  bronchial  respiration.  Apex  of 
heart  in  right  axilla.  Dilated  veins, 
paralysis  of  right  arm;  bulging  of 
intercostal  spaces 

Shortness  of  breath  for  some  weeks; 
no  other  symptoms.  At  first  visit 
whole  right  chest  flat  on  percussion, 
presenting  the  physical  signs  of  pleu- 
risy with  effusion.  Repeated  punc- 
ture negative,  except  small  quantity 
of  blood  at  one  time  containing  the 
usual  number  of  leucocytes.  Gradu- 
ally increasing  dyspncsa  and  signs  of 
thoracic  pressure  —  distension  of  tho- 
racic veins,  bulging  of  right  chest, 
oedcema  of  right  side  of  face.  Death 
after  an  illness  of  6  weeks 

Family  history  of  cancer.  After  a 
disease  of  chest  diagnosed  as  bron- 
chitis patient  had  persistent  harassing 
cough.  After  a  fall  pain  in  right  chest 
with  cough  and  fever.  Pneumonia  is 
diagnosed.  Since  that  time  not  well. 
Pain  in  shoulder  and  anterior  portion 
of  right  chest  radiating  from  above 
angle  of  right  scapula.  At  that  time 
there  was  very  slight  dulness  and 
slightly  diminished  breathing.  All 
other  organs  normal.  Later  oedcema 
of  right  hand  and  arm,  increasing 
dulness  under  clavicle  and  slight 
prominence  above;  entire  absence  of 
voice  and  breathing  over  greater  part 
upper  lobe.  Gradual  bulging  of  right 
chest  in  region  of  3  upper  ribs  anteri- 
orly; no  fever;  no  glands.  Increas- 
ing dyspnoea;  increasing  pain.  Clini- 
cal diagnosis :  tumor  in  chest  probably 
in  lungs.     Duration  22  months 

No  heredity;  always  in  good 
health.  2  months  before  admission 
inflammation  of  lungs.  Later  complete 
left  hemiplegia.  Clinical  diagnosis: 
cerebral  haemorrhage.     Sudden  death 


No  heredity.  Emaciation,  cough; 
symptoms  principally  brain  symptoms. 
Dulness  over  all  left  lung,  bronchial 
respiration,  diminished  motion;  fine 
rales  at  both  apices.  Liver  much 
enlarged  and  tender.  Icterus.  Clini- 
cal diagnosis:  pneumonia,  phthisis 
pulmonalis,  brain  tumor,  possibly 
old  apoplexy.  Duration  of  disease 
at  least  8  months 


SARCOMA 


259 


SPUTUM 

AUTOPSY   NOTES 

METASTASES 

MICEOSCOPE 

REMARKS 

No  details 

Right  lung  adherent  to 
chest  wall  and  seat  of  exten- 
sive new  growth.     No  other 
organs  involved 

None 

Alveolar 
structure. 
Small  round 
celled  sarcoma 
with  numer- 
ous lymph 
elements. 
Lympho- 
sarcoma 

Mucopuru  - 

Firm,  whitish-gray  tumor 

None 

Fibrous 

lent,  often 

occupying  right  upper  lobe. 

stroma;  cells 

bloody 

partly  broken  down  and 
eroding  clavicle  and  ribs. 
No  glands 

of  varying 
size  and 
shape;  where 
tumor  is  hard 
stroma  pre- 
dominates, 
where  it  is 
soft  and  med- 
ullary, almost 
entirely  cel- 
lular. Author 
calls  it  sar- 
coma 

No  details 

Bulky  tumor  at  root  of 
left  lung  extending  into  lung 
and  centred  around  main 
bronchus,  the  walls  of  which 
are  incorporated  in  the  tu- 
mor.    Large  hsemorrhagic 
cavity  in  right  corona 
radiata 

No  details 

Small 
round  celled 
sarcoma 

Bloody 

Large,  diffuse,  nodulated 

Liver, 

Alveolar 

Origin  probably  in 

tumor  left  lower  lobe  desig- 

brain, peri- 

structure 

Ijmiph  nodes 

nated  at  autopsy  as  primary 

bronchial 

with  thick 

carcinoma 

lymph 
nodes 

bands  of  fi- 
brous tissue 
arranged  in 
meshes;  ex- 
tremely fine 
reticuli  in 
meshes,  which 

260 


TABLE   II 


NO. 

AUTHOE 

SEX 

AGE 

LUNG     IN- 
VOLVED 

CLINICAL  SYMPTOMS 

54 

MlLIAN  ET  BeENABD, 

Biill.  de  la  Soc.  Anat. 
de  Paris,  1898,  p.  336 
Sarcome  aigu   du  Pou- 
mon;  Generalization, 
Bacteries  dans  les  tu- 
meurs 

F 

27 

L 

No  heredity;  no  syphilis.  _  4  months 
before  admission  while  in  perfect 
health,  sudden  pain  and  paresis  of 
both  legs.  Later  an  attack  of  pneu- 
monia. Since  then  cough,  dyspnoea, 
some  congestion  and  rales  at  both 
bases;  cyanosis;  high  fever;  para- 
lytic and  spine  symptoms.  Clinical 
diagnosis  varied;  last  tuberculosis. 
Duration  about  4  months 

65 

MiiiiAN  ET  Mante, 
Soc.  Anat.  de  Paris, 
Vol.  76,  1901,  p.  82 

Sarcome     primitif     du 
Poxunon 

M 

31 

R 

History  of  syphilis.  Admitted  for 
brain  symptoms.  One  year  previ- 
ously had  severe  bronchitis;  since 
then  some  cough,  dyspnoea,  emaciation, 
fine  rales  over  both  bases.  Clinical 
diagnosis:  syphilitic  hemiplegia.  Sub- 
comatose  state;  apoplectic  attack, 
increasing  fever.  Death  about  1  week 
after  admission 

66 

MiRINBSCU   ET   BaHON- 
CEA, 

Revue     mens,     des 
Malad.   de  I'enfance, 
Paris,  1894,  XII,  82- 
86 
Sarcome     primitif     du 
Poumon 

F 

14 

R 

Uncle  died  of  cancer.  3  months 
before  admission  acute  disease,  prob- 
ably pneumonia.  Acute  symptoms 
improved,  but  general  condition  re- 
mained bad.  On  admission  flatness 
in  lower  posterior  portion  of  right 
chest  above  and  below  to  spine  of 
scapula  and  in  right  subclavicular 
region.  Some  pleuritic  friction  at 
right  base.  Spasmodic  cough  like 
whooping  cough.  Exploratory  punc- 
ture of  thorax  negative.  All  other 
organs  apparently  healthy.  Dulness 
extends,    involving    nearly    whole    of 

right  lung.  Breathing  rough  and 
diminished  with  amphoric  note.  Soon 
signs  of  thoracic  pressure  —  cyanosis 
of  face,  cedcema,  dilatation  of  super- 
ficial veins  of  chest,  hoarseness,  in- 
tense attacks  of  dyspnoea.  Death  from 
suffocation  more  than  a  month  after 
admission  to  the  hospital 

67 

Mora, 

M 

Not 

Both 

Toper  and  formerly  mine  worker. 

Ann.  univ.  de  Med.  e 

stated 

Admitted  in  moribund  condition;    no 

SARCOMA 


261 


AUTOPSY    NOTES 


METASTASES 


MICROSCOPE 


Green,  pro- 
fuse hae- 
moptysis 


No  details 


Mucus, 
bloody  at 
first. 
Nothing 
charac- 
teristic 


Left  lung  almost  entirely 
transformed  into  large  cav- 
ity, the  walls  of  which  are 
lined  with  whitish-gray  neo- 
plasm; cavity  contains  white 
liquid.  Also  tumor  sur- 
rounding 5th  and  6th  ribs 


Irregular  tumor  near  hilus 
of  left  lung;    showed  some 
fluctuation  and  on  incision 
seemed  composed  of  a  num- 
ber of  cavities  with  soft  walls 
filled  with  thick,  creamy 
greenish  fluid.     In  right 
lower  lobe  a  solid  tumor 
size  of  a  large  orange,  sur- 
rounded by  a  series  of  cavi- 
ties containing  a  purulent, 
viscid,  greenish  or  chocolate 
colored  fluid,  which  can  in 
some  places  be  lifted  by  the 
fingers  in  strings  the  size  of 
a  penholder.     Atelectatic 
lung  tissue  around  the  tumor 
traversed  by  whitish  bands 

Right  pleura  almost  ob- 
literated ;  slight  yellow  effu- 
sion in  left.     Right  visceral 
pleura  everywhere  studded 
with  nodules,  whitish  yellow. 
Nearly  whole  of  right  lung 
occupied  by  soft  pulpy  tu- 
mors;  in  the  centre  a  large 
cavity  formed  by  degener- 
ated tumor  and  filled  with 
puriform  material.     All 
other  organs  healthy 


No  details 


Both  lungs  from  root  to 
base  and  more  anteriorly 


Medias- 
tinal and 
hilus  lymph 
nodes; 
bodies  of 
2nd  and  3rd 
vertebrae 
invaded  by 
tumor  ex- 
tending into 
canal  and 
compressing 
cord 

Anterior 
mediasti- 
num, spleen 
In  brain  a 
multitude  of 
small  cavi- 
ties  filled 
with  green- 
ish or  choco- 
late colored 
pus.     All 
other  organs 
healthy 


Medias- 
tinal and 
bronchial 
glands 


are  filled  with 
small  round 
cells.  Alveolar 
round  celled 
sarcoma 

Small 
round  celled 
sarcoma  in 
part  resem- 
bling lympho- 
sarcoma ; 
large  round 
cells  also. 
Sarcomatous 
lymphangitis 


Sarcoma 


Round  and 
spindle  celled 
sarcoma 
originating 
from   conneC' 
tive  tissue 
of   septa  and 
alveoles 


Bronchial 

glands 


Small 
round  and 


262 


TABLE   II 


58 


59 


60 


61 


Chir.,     Milan,     1875, 
Vol.  231,  p.  11-17 


Moore, 

Lancet,    1890,    II.   p. 
876 


Pal,  J. 

Jahrbuch  der  Wiener 
K.K.  Krankenanstalt, 
III,  1894.  Vienna, 
1896,  p.  545 

Lymphosarkom     der 
Lunge 


Pater  et  Rivet, 
Arch,  de  med.  experi- 
mentale    et    d'anato- 
mie  path.  Vol.  XVIII 
1906,  p.  85 

Sur  un  Cas  de  Sarcome 
primitif  du  Poumon 


Pfrttz 

Diss.'  Berlin,  1896 


M 


M 


M 


M 


10 


21 


26 


38 


LUNG     IN- 
VOLVED 


R 


Both 


CLINICAL   STMPTONS 


history    obtainable;      could    not    be 
examined.     Death  from  suffocation 


Duration  4  months.  Signs  of  pres- 
sure on  recurrent  laryngeal  and  sym- 
pathetic; left  pulse  absent;  some 
fever.     Constriction  of  left  subclavian 


Well  until  5  months  ago.  Suddenly 
severe  pain  in  stomach,  headaches, 
weakness,  dizziness,  constipation  last- 
ing 3  or  4  days  at  a  time,  but  ending 
in  spontaneous  evacuation.  Pain  in 
left  chest,  legs,  and  feet;  some  jaun- 
dice; pain  all  over  abdomen.  Later 
vomiting  after  almost  every  meal; 
then  pain  in  right  chest  and  about 
heart;  some  dyspnoea.  No  vomiting 
for  3  months,  but  all  other  complaints 
worse.  On  admission  jaundice,  some 
cyanosis;  dulness  from  3rd  rib  down- 
wards, merging  into  heart  dulness; 
flatness  posteriorly.  Diminished  frem- 
itus and  breathing.  Dilated  veins 
over  abdomen;  Uver  enlarged  and 
tender.  Increasing  dulness  over  both 
lungs.  Systolic  murmur;  accentua- 
ted 2nd  sound.  Apex  beat  to  left 
of  mammUlary  line.  Aspiration  of 
both  pleurEe  withdrew  bloody  serum. 
Death  2  days  after  admission.  Noth- 
ing said  about  cough  or  sputum 

Illness  commenced  with  cough  and 
loss  of  weight.  Gradual  swelling  of 
numerous  peripheral  Ij'mph  nodes. 
On  admission  harassing  cough  with 
dyspncea  and  cyanosis;  hoarseness; 
enlarged  lymph  nodes  everywhere. 
Paralysis  of  right  vocal  cord.  Dulness 
at  left  base  with  rales.  Some  diar- 
rhoea. Rapid  decline.  Fever.  Red 
cells  3,174,000;  whites  8,370;  poly- 
nuclears  71%;  eosinophiles  0;  lym- 
phocytes 9;  transitionals  17.  Clinical 
diagnosis:  tuberculosis.  Duration 
about  1  year 

Sudden  onset  with  cough,  pain  in 
chest,  dyspnoea,  night  sweats.  Ca- 
chexia; slight  fever.  Swelling  of 
neck,  dislocation  of  larjmx;  paralysis 
left  vocal  cord.  CEdoema  left  chest; 
dilated  veins.  Dulness  and  diminished 
respiration  over  left  chest.  Aspira- 
tion clear  serum.  Needle  enters 
hard  tumor.  Enlarged  axillary  glands. 
Duration  of  disease  about  3  months 


S.IRCOMA 


263 


SPUTUM                      AUTOPSY  NOTES 

METASTASES 

MICROSCOPE 

EEMAEK8 

than  posteriorly  trans- 

enlarged; in 

spindle  celled 

formed  into  soft  pinkish  tu- 

part cheesy 

sarcoma. 

mor  adherent  to  pleura  and 

and  calcare- 

Pigment and 

diaphragm.     Upper  portion 

ous 

connective 

of  both  lungs  interstitial 

tissue  indu- 

fibrosis 

ration  of  rest 
of  lung 

No  details 

Nearly  entire  upper  por- 

Pleura, 

Round  and 

tion  of  left  lung  replaced  by 

right  lung, 

spindle  celled 

whitish  tumor 

mediastinal 
and  inguinal 
lymph  nodes 

sarcoma 

No  details 

Right  lower  and  middle 
lobes  replaced  by  tumor  lar- 
ger than  child  s  head  with 
only  a  trace  of  compressed 
lung  tissue  remaining  at 
its  peripherj\     The  greater 
part  of  the  tumor  is  hard; 
some  places  soft  on  section 
with  round  pigmented  areas 
corresponding  to  bronchial 
glands,  also  here  and  there 
the  lumen  of  a  bronchus  can 
be  seen 

Both  auri- 
cles, pericar- 
dium; head 
of  pancreas, 
retroperito- 
neal lymph 
nodes;  com- 
pression of 
lower  cava 
by  tumor 

No  details 

No  details 

Numerous  tumor  nodules 

_  Medias- 

Large 

Author  claims  origin 

at  both  bases;  more  in  left 

tinal  mesen- 

round celled 

from  intra-alveolar 

teric. 

sarcoma 

tissue  at  left  base. 

peripheral 

Numerous  nodules  in 

lymph 

liver  shown  to  be 

nodes; 

tubercular,  contain- 

nodes at 

ing  bacilli 

hilus  of 

liver 

Occasion- 

Lympho-sarcoma of  left 

Bronchial, 

Lympho- 

ally bloody 

lung,  bronchi,  pleura,  and 
mediastinum.     Bronchiec- 
tases, purulent  bronchitis, 
indurative  pneumonia  of  left 
iung;  (xdoema  of  right  lung. 
Degeneration  of  left  recur- 
rent ;  myo-  and  endocarditis 

cervical, 
axillary 
lymph 
nodes;  left 
auricle 

sarcoma 

264 


TABLE   II 


62 


63 


64 


65 


Log.  cit. 


PiTOT, 

Arch,  de  Med.  et  de 
Pharm.  MU.,  Vol..  34, 
Paris,  1899,  p.  306 
Sarcome  primitif  du 
Poumon  a  Marche 
rapide 


Poison  et  Robin, 
Gaz.  mfed.   de  Paris, 
1856,   No.   9   Quoted 
(from  Fuchs) 

Tumor  Fibroplastique 
du  Poumon 

PoLACci  E  La  Franca, 
Arch.  Ital.   de    Med. 
Intern.,   Palermo, 
1901,  Vol.    IV,    fasc. 
1-2,  p.  408 

Enorme  Sarcoma  primi- 
tive del  Polmone  con 
sintomi  di  pseudo 
mixedema 


M 


M 


M 


53 


20 


30 


55 


LUNG     IN- 
VOLVED 


R 


R 


CLINICAL    SYMPTOMS 


No  heredity.  After  some  gastric 
disturbance  anorexia,  cough,  pain  in 
chest,  night  sweats,  dyspnoea.  Dimin- 
ished respiratory  motion  over  right 
chest;  posteriorly,  flatness  and  dimin- 
ished voice  and  breathing.  Aspira- 
tion: bloody  serum.  Tumor  appears 
over  right  clavicle.  Right  chest  be- 
comes retracted;  stridorous  respira- 
tion; club  fingers.  Aspirating  needle 
now  enters  hard,  firm  tissue.  Dura- 
tion about  1  year 


Tubercular  family  history.  Always 
well.  Cough  since  a  month  before 
admission.  Looks  well.  On  both 
lungs  sonorous  and  sibilant  _  rales. 
No  dulness  anywhere.  No  lesions  in 
other  organs.  Diagnosis:  bronchitis 
and  grippe,  which  was  then  epidemic. 
No  fever.  Some  weeks  later  dyspnoea; 
slight  dulness  middle  of  left  lung 
behind.  Dulness  increases  towards 
apex.  Severe  pain  at  left  base.  Later 
pleural  effusion,  heart  displaced  to 
right;  fever.  800  c.c.  of  bloody  serum 
aspirated.  Patient  feels  better  but 
physical  signs  persist.  Diagnosis: 
tuberculosis.  Repeated  aspirations. 
Diilness  increases  in  front  and  behind. 
Left  chest  measures  2  cm  more  than 
right.  900  c.c.  greenish  fluid  aspirated. 
Left  jugular  thrombosed;  cedoema  of 
that  side  of  face,  neck,  and  shoulder. 
2  more  aspirations  without  result. 
Thrombosis  popliteal  vein.  Death 
with  intense  dyspnoea  and  suffocation 
about  2 1  months  after  admission 

Cough,  night  sweats,  dyspnoea,  pain 
in  left  chest,  emaciation.  Later  pleu- 
risy and  signs  of  consolidation  of  left 
lung;  cyanosis;  intense  asphjrxia. 
Duration  about  6  months  or  over 


Disease  began  with  swelling  of  right 
carotid,  which  gradually  invaded  right 
side  of  neck  and  upper  part  right  chest; 
later  left  side  also  involved.  Increas- 
ing difficulty  in  breathing  and  swallow- 
ing, dilated  veins  in  chest  and  neck. 
Cough,  pain  in  chest,  nocturnal  attacks 
of  dyspnoea,  cedoema  of  lower  extrem- 
ities. Dulness  over  right  chest  below 
3rd  interspace;  diminished  voice  and 
breathing ;  from  spine  of  scapula  down- 
wards bronchial  respiration ;  absence  of 
breathing  at  base.  Left  lung  normal. 
Duration  about  9  months 


SARCOMA 


265 


SPUTUM 

AUTOPSY    NOTES 

METASTASES 

MICROSCOPE 

REMARKS 

Mucoid,  no 

Tumor  degeneration  of 

Bronchial, 

Small  round 

Origin    probably 

tubercle 

right  main  bronchus,  some- 

retrobron-_ 

celled   sar- 

from   small  lymph 

bacilli, 

what  in  left  bronchus  and 

chial,  cervi- 

coma retain- 

nodes within  the  lung 

later 

in  trachea;  at  bifurcation 

cal,  axillary 

ing   alveolar 

straw- 

penetrates right  upper  lobe 

lymph 

structure  of 

berry  col- 

from hilus  along  bronchi. 

nodes,  skin, 

lung  due  to 

ored  con- 

Large bronchiectatic  cavi- 

liver, and 

persistence  of 

taining 

ties  in  lower  lobe 

kidneys 

septa 

bronchial 

casts  and 

great 

numbers 

of  large 

round 

epithelial 

cells 

At  first  mu- 

Left lung  almost  entirely 

Tumor 

Round  celled 

coid, 

replaced    by   large    tumor 

size  of 

sarcoma 

later 

everywhere  adherent  to  cos- 

orange in 

bloody, 

tal  pleura.    Tumor  softened 

liver  with 

finally 

in  some  places  and  resem- 

cavity in 

typical 

bles   brain  substance;   in 

centre  con- 

"currant- 

other  places  grayish  masses 

taining  col- 

jelly," no 

traversed  by  bands  of  fibrous 

loid  mate- 

tubercle 

tissue.     No  enlarged  glands 

rial.     All 

bacilli 

at  hDus.    Veins  in  left  neck 
thrombosed  and  merged 
into  nodulated  tumor  at 
base 

other 

organs 

healthy 

Repeated 

In  the  lumen  of  bronchi. 

No  details 

Spindle  celled 

hsemop- 

on   surf  ace  of  lung  and   in 

fibroplastic 

tyses 

lung  tissue  itself  soft  whitish 
encephaloid  masses 

sarcoma 

No  details 

Fluid    in    right    pleura. 

Bronchial 

Round  celled 

Heart  dislocated  to  left.   All 

lymph 

sarcoma 

of  right  lung  except  tip  oc- 

nodes 

cupied   by  large  nodulated 

tumor.     Enlargement  of 

right  lobe  of  thyroid 

266 


TABLE    II 


66 


67 


68 


69 


70 


71 


POLLAK, 

Dis.  Wiirzbtirg,  1897 

Ein  Fall  von  primarem 

Lungensarkom 


M        71 


POOHB, 

The  Lancet,  London, 

1895,  I,  p.  870 

A  Case  of  Tumor  of  the 

Lung 


Porter, 

British  Med.  Jour., 
1885,  II,  448 


Powell, 

Brit.  Med.  Jour.  1879, 
p.  115 

Sarcomatous  Disease  in- 
vading the  Lung  and 
Occluding  its  Bronchi 


Ranglahbt, 

Bull.    Soc.  Anat.   de 

Paris,  1893,  Vol.  VII, 

p.  591 
Sarcome     primitif     du 

Poumon  Gauche 


Reymond,  E. 

Bull,  de  la  Soc.  Anat. 


M 


M 


M 


M 


20 


LUNG     IN- 
VOLVED 


R 


39 


Not 
stated 


34 


23 


R 


CLINICAL    SYMPTOMS 


Various    tropical    diseases.     Death 
with  symptoms  of  icterus  gravis 


Quite  healthy  untU  one  morning  on 
getting  up  sudden  shortness  of  breath. 
Remained  in  bed  for  some  weeks. 
Later,  while  walking,  severe  pain  in 
back.  Went  to  bed  and  then  to 
hospital.  SHght  dyspnoea  on  exer- 
tion, slight  cough.  Left  side  impaired 
respiratory  motion.  Below  3rd  rib 
absolute  dulness.  Absence  of  voice 
and  breathing  over  this  area;  some 
bronchial  breathing;  similar  condi- 
tions below.  Heart  dislocated  to 
right.  Aspiration  negative.  Left 
chest  increased  in  size;  swelling  in  left 
mammary  region ;  slight  fever.  Later 
oedoema  of  left  chest;  dilated  veins. 
Small  tumor  over  head  of  right 
humerus.  Dulness  extended  over  to 
right  chest.  No  pain  at  any  time. 
Duration  about  4  months 

Dyspnoea,  palpitation,  cough.  Pain, 
dysphagia.  CEdcema  feet  and  left 
forearm.  Flatness  upper  left  lung; 
dulness    at    base;     feeble    voice    and 

breathing 


Haemoptysis  of  2  weeks  duration. 
Cough  and  haemoptysis  recurred  few 
months  later.  Jaundice.  Dulness  at 
base  to  spine  of  scapula  and  nipple 
with  diminished  voice  and  breathing, 
later  extending  over  upper  lobe.  Pain 
in  chest;  intense  dyspnoea 


No  heredity.  Pain  in  left  chest. 
Pregnancy;  normal  labor.  Continued 
pain;  negative  puncture.  Later  ex- 
pansion of  left  chest.  Flatness  and  ab- 
sence of  breathing  sounds  all  over  chest. 
Harassing  cough.  Dislocation  of  heart 
to  right.  Debility  and  emaciation. 
Dilatation  of  superficial  veins.  Qildce- 
ma  of  lower  extremities.  Bloody  fluid 
in  left  pleura.  Diagnosis  made  during 
life.     Duration  about  16  months 

Sudden  onset  after  "cold"  with 
dyspnoea,  severe  pains  in  left  shoulder 


SARCOMA 


267 


AUTOPSY    NOTES 


METASTASES 


MICROSCOPE 


No  details 


Scant,  once 
or  twice 
bloody 


Bloody 


Mostly 
bloody 


Mucoid  and 
bloody, 
haemop- 
tysis 


Bloody,  no 
tubercle 


From  root   of  right  lung 
and  extending  along  bron- 
chial ramifications,  medul- 
lary   infiltration,    particu- 
larly of  the  alveolar  septa; 
compression  of  bronchi  and 
blood  vessels 


Whole  of  left  chest  filled 
with  soft  growth  covered  by 
thickened  pleura  firmly  ad- 
herent to  chest  wall.  Upper 
anterior  portion  of  tumor 
covered  by  shell  of  collapsed 
lung 


Liver  and 
lymph 
nodes  of  lig. 
hepatoduo 
denale 


Large  tumor  occupying 
entire  left  upper  lobe,  and 
enveloping  root,  transverse 
aorta,  left  carotid  and  sub- 
clavian. Pneumonia  in 
lower  lobe 

Large  lymphomatous 
growth  in  posterior  medias- 
tinum occupying  bifurcation 
and  extending  into  lung,  in- 
volving two  lower  bronchi 
and  completely  occluding 
the  lower  one.  Middle  lobe 
entirely  occupied  by  tumor. 
Bronchiectases  in  lower  lobe 

Left  lung  totally  replaced 
by  soft  encephaloid  tumor 
with    cavities   containing 
bloody  and  greenish  con- 
tents.    Right  lung  normal 


Nearly  whole  of  left  lung 
converted  into  large  tumor 


Right  lung, 
mediastinal 
lymph 
nodes,  liver 
and  over 
humerus 
and  scapula 


No  details 


Liver,  left 
kidney  and 
peritoneal 
lymph 
glands 


Absolutely 
none  any- 
where 


Glands  at 
hilus  only 


Round  celled 
sarcoma  pro 
liferating 
mainly  in  the 
fibrous  tissue 
of  the  intra- 
lobular and 
intra-alveolar 
septa  of  the 
smaller 
bronchi 

Round  celled 
sarcoma 


Round  celled 
sarcoma 


Lympho-sar- 
coma 


Spindle  celled 
sarcoma 


Spindle  celled 
sarcoma;  no 


268 


TABLE   II 


de  Paris,    1893, 
VIII,  p.  256 
Sarcome     primitif 
Poumon  Gauche 


Vol 
du 


72  ROLLESTON,  H.  D. 

Transact.  Path.  Soc 

of  London,  1891,  p.  54 

Myxo-sarcoma  of  Lung 


73 


74 


75 


RoLLESTON  &  Trevor, 
British  Med.  Jour., 
Feb.  14,  1903 

Primary  Sarcoma  of  the 
Lung 

Roth,  Ludwig, 
..  Diss.  Miinchen,  1904 
Uber    primares    Lun- 
gensarkom,  etc. 


Rttetimeyer, 

Corresp.-blatt     fiir 
Schweizer  Arzte, 
1886,  XVI,  169-199 


M 


LUNG    IN- 
VOLVED 


33 


M 


13 


45 


28 


R 


CLINICAL   SYMPTOMS 


radiating  into  arm  and  fingers.  Im- 
proved for  a  time,  but  symptoms  re-ap- 
peared with  loss  of  flesh  and  haemopty- 
sis. Examination  then  showed  nothing 
but  slight  pericardial  friction.  Clinical 
diagnosis  at  that  time:  rheumatism 
with  dry  pericarditis.  Later  increas- 
ing pain,  slight  fever.  Bulging  of  left 
chest;  heart  dislocated  to  right.  Flat- 
ness from  left  clavicle  downwards; 
diminution  of  breathing  sounds.  Re- 
peated cultures  negative.  Heart 
sounds  heard  clearly  all  over  left 
chest.  Blood  normal.  Fever  up  to 
104.     Duration  about  5  months 

No  clinical  history  except  that 
paracentesis  of  thorax  gave  mucous 
fluid 


Recurrent  pains  in  right  chest  and 
all  symptoms  of  empyema.  Aspira- 
tion at  first  negative;  later  small 
amount  of  bloody  fluid.  Resection 
of  rib  showed  solid  growth 

Always  well.  December,  1902,  pain 
in  chest  and  cough.  Got  better,  but 
had  renewed  attack  in  Jan.,  1903. 
Never  quite  well  since  then.  In 
beginning  of  May,  1903,  severe  pain 
in  chest  and  back;  impossible  to  walk 
upright.  While  walking  sudden  feel- 
ing as  if  something  burst  in  his  ab- 
domen. Signs  of  paralysis  after  that. 
On  admission  10th  to  12th  thoracic 
vertebrse  very  tender;  to  the  left 
of  their  spines  a  fluctuating  tumor 
presents  size  of  the  palm  of  the  hand. 
Flatness  over  entire  right  apex. 
Rales  over  both  lungs.  Clinical 
diagnosis:  tuberculosis  of  lungs  and 
spine.  Later  puncture  of  abscess. 
Rapid  decline,  intense  dyspnoea.  Pains 
in  both  legs;  emaciation;  death 


No  heredity.  Sudden  onset  with 
pain  in  side  and  moderate  fever.  Pain 
disappears;  some  dyspncsa  remains; 
dry  cough.  Chills  and  fever;  dulness 
over  left  base.     Exploratory  puncture 


SARCOMA 


269 


SPUTUM 

AUTOPSY   NOTES                  METASTASES 

MICROSCOPE 

EEMARK8 

bacilli 

filling  greater  part  of  chest. 
Some  remnants  of  lung  tis- 
sue under  pleura.   Cavity  in 
centre  of  tumor  contains 
large  amount  of  fresh  blood 

remnants  of 

pulmonary 

structure 

No  details 

Left  lower  lobe  completely 

Bronchial 

Small  celled 

occupied  by  a  mass  of  new 

glands;  8th, 

myxosarcoma 

growth    almost    completely 

9th  and  10th 

replacing  lung  tissue.  Upper 

left  ribs 

lobe   compressed   and   infil- 

trated with  new  growth  in 

its  lower  parts.      Parts    of 

the  tumor  calcified;  honey- 

combed in  parts  with  cysts 

containing    gum-like   fluid 

consisting  chemically  of  al- 

bumin   and    mucin.      The 

tumor  projects  into  pericar- 

dial- cavity 

No  details 

Whole  right  lung  except 
apex   converted    into   soft 
gruel-like  growth  with  hsem- 
orrhagic  areas 

None 

Spindle  celled 
sarcoma 

Bloody  sev- 

Right lung  adherent.  Ne- 

Peribron- 

Alveolar 

Author    designates 

eral 

oplasm  size  of  a  fist  in  right 

chial  glands 

structure ; 

the  tumor  as  a  small 

weeks 

upper  lobe.    Pneumonic  in- 

stroma of  fi- 

round  celled  sarcoma 

before 

filtration   of    lower   lobe. 

brous_  strands 

probably    originating 

death 

Bronchi    infiltrated   with 
tumor.    Tumor  almost  com- 
pletely replaces  lung  tissue 

containing 
dilated  and 
congested 
blood  vessels. 
Tumor  con- 
sists of  small 
round  cells 
with  large 
nuclei  and 
small  proto- 
plasmatic 
bodies.  Walls 
of  alveoles 
lined  with 
similar  cells. 
Large  areas 
of  tumor  ne- 
crotic 

in  lung  itself 

Green,  later 

Whole     left     lower     lobe 

None  any- 

Small round 

Origin    from    lung 

severe 

practically  one  large  tumor 

where 

and  spindle 

tissue  itself 

haemop- 

surrounded by  thin  layer  of 

celled  sar- 

tysis 

compressed    lung    tissue. 
Bronchi  normal 

coma 

270 


TABLE    II 


NO. 

AUTHOR 

SEX 

AGE 

LUNG     IN- 
VOLVED 

CLINICAL   SYMPTOMS 

negative.     Later  flatness  with  absence 

of  voice  and  breathing  over  left  base. 

CUnical  diagnosis:    encapsulated  em- 

pyema.    Rib   resection    showed   soft, 

reddish  tumor  masses  in  lung.     Dura- 

tion about  2  years 

76 

Sangalli, 

Gaz.  med.  Lombarde, 
1897,  p. 226 

Osservazione    sul    Sar- 
coma della  Pleure   e 
dei  Polmoni 

M 

49 

Both 

Increasing  dyspnoea 

77 

Loc.  CIT. 

M 

61 

R 

Clinical  diagnosis:  right  pleurisy 
with  effusion.  Aspiration  negative. 
Increasing  cough,  dyspnoea,  dysphagia. 
Bougie  in  oesophagus  showed  nothing 

78 

SCHECH, 

Virch.   Arch.   f.   klin. 
Med.,  Vol.   47,    1891, 
p.  411 
Das  primare  Lungen- 
sarkom 

M 

57 

R 

Acute  onset  with  profuse  haemop- 
tysis. Nothing  found  on  lungs. 
Repeated  severe  hsemoptyses.  Year 
and  half  later  slight  dulness,  dimin- 
ished fremitus  and  absence  of  breath- 
ing over  right  base.  Some  rales. 
Embolism  was  suspected.  No  dysp- 
noea, fever,  pain,  or  emaciation. 
Repeated  hgemorrhages.  Year  later 
dyspnoea,  intense  pain,  cough.  Grad- 
ually complete  paralysis  up  to  mam- 
miUary  line.  Increase  of  dulness  over 
entire  right  chest.  Duration  of  dis- 
ease at  least  3  years 

79 

SCHNICK, 

Diss.  Greifswald,  1899 
Ein  Fall  von  primarem 
Spindelzellensarkom 
der    Lungen    gepaart 
mit  Tuberkulose 

M 

36 

R 

3  weeks  before  admission  bloody 
sputum  and  pain  in  right  chest.  In- 
creasing dyspnoea  and  weakness.  Phys- 
ical signs  of  tuberculosis  in  both 
apices.  Hectic  fever.  Dulness  over 
upper  portion  right  chest;  loud  vesic- 
ular breathing;   rales 

80 

Shewen, 

Austral,    med.    Gaz., 
1885,  Vol.  IV,  p.  81 

Case  of  Sarcoma  of  Left 
Lung    involving    the 
Diaphragm    and   the 
Spleen 

M 

31 

L 

Chill  and  congestion  of  lung;  never 
quite  well  after.  Gradually  dyspnoea, 
enlargement  of  left  chest.  Dilated 
veins;  heart  displaced  to  right.  Dul- 
ness with  absence  of  voice  and  breath- 
ing over  left  chest.  No  cough,  _  no 
fever,  no  pain.  Aspiration  negative. 
Tumor  diagnosed  during  life.  Dura- 
tion of  disease  between  2  and  3  years 

81 

SiLVA, 

Gaz.  degli  Ospidali  e 

M 

63 

L 

No  heredity;  no  lues.  Illness  be- 
gan 7  months  ago  with  difficulty  in 

SARCOMA 


271 


SPUTUM 

AUTOPSY    NOTES 

METASTASES 

MICROSCOPE 

EEMAHKS 

No  details 

Numerous  nodules  in  both 
lungs,  more  in  right,  often 
confluent  and  merging  into 
large  masses 

No  details 

Round  celled 
sarcoma  with 
calcification 

No  details 

Old    tuberculosis    of    left 

Bronchial 

Round  celled 

apex;  numerous  larger  and 

and  medias- 

fibro-sarcoma 

smaller  nodules  throughout 

tinal  lymph 

right  lung,  also  strips  of  in- 

nodes and 

filtration    of    white    tumor 

oesophagus 

throughout    lung.       Tumor 

proliferates     into     wall     of 

oesophagus.     Tumor  masses 

surround  and  compress  de- 

scending aorta,  oesophagus, 

both     bronchi,    and     right 

auricle 

Purulent, 

Bloody    fluid    in  right 

Spleen; 

Round  celled 

green 

pleura.    Almost  entire  right 
lung    converted    into    firm 
white  tumor  mass  enclosing 
cavities  filled  with  necrotic 
material.    Left  lung  normal 

pleura. 
Brain  and 
cord  not 
examined 

fibro-sarcoma 

Profuse, 

Fresh  endocarditis.     Tu- 

None 

Typical 

muco- 

berculosis of  both  lungs.    In 

spindle  celled 

purulent, 

right  middle    lobe    a    large 

sarcoma 

occasion- 

tumor,    encapsulated     and 

ally 

containing    a    cavity    filled 

bloody ; 

with  degenerated  tumor  ma- 

contains 

terial  ;  in  part  chalky  degen- 

tubercle 

eration;  numerous  tubercle 

bacilli 

bacflli 

No  details 

Left  chest  entirely  occu- 

Diaphragm 

Small  round 

Origin   from   bron- 

pied by  tumor  of  left  lung 

and  spleen 

celled  sar- 

chial glands 

displacing   heart   and  com- 

coma 

pressing  right  lung 

Tenacious, 

Bloody  fluid  in  left  pleura. 

No  details 

No  details 

bloody, 

Nearly  whole   of  left   lung 

272 


TABLE   II 


82 


83 


84 


della  cliniche  Milana, 
XXIII,  1902,  seria  11, 
p.  1236 

Sul    Sarcoma    primario 
del  Pulmone 


Smith,  W.  G. 
Dublin    Jour. 
Science,     1881, 
72,  p. 452 


Med. 
Vol, 


SPILLMAJm  AND    HaUS- 
HALTER, 

Gaz.  Hebd.,  1891,  p. 

587 

Du  Diagnostic  des  Tu- 

meurs    malignes     du 
Poumon 


Steell,  Geaham, 
Lancet,  1894, 
I.  p.  388, 
Clinical  Lecture 
on  Case  of  Tumor 
of  Lung 


M 


M 


M 


'LUNG     IN- 
I    VOLVED 


Not 
stated 


42 


45 


85 


Sutton, 

Lancet,    1869,    I,    p. 
459 


11 


R 


R 


CLINICAL    SYMPTOMS 


swallowing.  For  1  month  icterus  and 
mUk  diet.  For  5  months  severe 
cough;  no  fever.  Some  nausea,  but 
rarely  vomiting.  Severe  pain  in 
epigastrium  and  behind  sternum  radi- 
ating to  left  chest  and  shoulder.  On 
admission  much  emaciation.  Im- 
paired respiratory  motion  of  left  chest; 
flatness  over  whole  left  chest  except 
shght  space  at  base.  All  over  flat 
area  absence  of  breathing  and  frem- 
itus. Oesophageal  sound  finds  resist- 
ance 32  cm.  from  teeth.  Puncture 
jaelds  only  a  few  drops  of  blood; 
needle  enters  hard,  firm  tumor  mass. 
Gradual  decline;  intensest  dyspncsa, 
cyanosis.  Slight  fever.  Clinical  diag- 
nosis: primary  sarcoma  of  lung 

Pleurisy  of  right  side  2 1  years  before. 
Since  then  never  quite  himself ;  breath- 
ing always  short.  Later  principally 
cerebral  sjonptoms,  paralysis,_  etc., 
due  to  haemorrhage  and  softening  in 
pons.  4  or  5  weeks  before  death 
haemoptysis,  cough.  Dulness  below 
_ht  clavicle  extending  downwards; 
complete  absence  of  breathing  sounds. 
Later  temperature  to  102.  Later 
complete  dulness  of  entire  right  chest. 
Excessive  sweating;  foetid  breath. 
Duration  of  illness  from  development 
of  paralysis,  3  months 

Occasional  pain  in  left  chest;  biil- 
gmg  of  entire  left  chest.  Irregular 
areas  of  dulness  increasing  to  flatness; 
absence  of  voice  and  breathing. 
Emaciation  and  sweating.  Various 
symptoms  referable  to  the  heart.  No 
dyspnoea;  no  cough.  Duration  of 
disease  about  2  years 


Good  health  until  haemoptysis, 
followed  by  failure  of  health.  No 
cough,  no  expectoration,  and  no 
physical  signs  on  lungs  for  months. 
Later  much  pain  in  right  chest  and 
large  quantities  of  putrid  expectora- 
tion as  from  ca\dties.  Upper  right 
chest  fuller  than  left;  impaired  res- 
piratory motion.  Absolute  flatness 
o  f  upper  right  lobe  with  later  de- 
velopment of  tympanitic  sounds  and 
other  signs  of  cavity.  Dilatation  of 
veins  of  upper  right  arm  and  right 
chest.  Slight  temperature  shortly  be- 
fore death 

Cyanosis,  dyspncea.  Absolute  flat- 
ness and  absence  of  breathing  sounds 
throughout     left    chest.     Heart     dis- 


SARCOMA 


273 


no  tuber- 
cle bacilli 


transformed  into  hard,  dark, 
greenish  tumor  mass 


Repeated 
haemop- 
tysis 


None 


AUTOPSY    NOTES 


Right  lung  adherent.  En 
capsulated  empyema  with 
putrid  pus.  Upper  |  of  lung 
converted  into  lobulated 
tumor  separated  by  highly 
pigmented  septa.  Lower 
third  completely  gangrenous 


None  at 
first,  later 
abun- 
dant,  ex- 
tremely 
foetid.  No 
micro- 
scopic ex- 
amina- 
tion 


No  details 


Large  tumor  filling  nearly 
all  of  left  chest  dislocating 
heart  to  right  and  pushing 
diaphragm  downward.  Ori 
gin  of  tumor  right  upper 
lobe.  Peripheral  areas  of 
tumor  surround  a  cyst-like 
central  mass;  entire  central 
mass  surrounded  by  com 
pressed  lung  tissue 

Both  pleurae  adherent. 
Right  pleura  practically  ob- 
literated; no  effusion.  Large 
cavity  in  right  upper  lobe 
with  irregular  soft  walls  of 
grayish-white  tumor.  Tu 
mor  size  of  a  small  orange 
projects  into  cavity.  Only 
slight  traces  of  lung  tissue 
remain  in  upper  lobe 


Medullary  cancer  occupy- 
ing entire  left  chest.  "  Left 
lung  collapsed,  pushed  back- 


METASTASES 


Mediastinal 

lymph 

nodes 


None 


None;  not 
even  in  mid- 
dle and  low- 
er right  lobe 


MICROSCOPE 


Small  round 
celled  sar- 
coma 


Cystic 
fibro-sarcoma 


Simply  said 
to  be  lympho- 
sarcoma 


None 


No  details 


19 


274 


TABLE   II 


86 


87 


A    Case    of    Medullary 
Cancer  of  Lung  simu 
lating  Pleuritic  Effu- 
sion 

Vandervelde,  Paul, 
Jour,  de  Med.  Chir. 
et  Pharm.  Bruxelles, 
Vol.  94,  1892,  p.  193 

Un  Cas  de  Sarcome  en- 
cephaloide  primitif  du 
Poumon,  etc. 


Walch, 

Bull,  de  la  Soc.  Anat. 
1893,  p.  90 

Cancer  du  Poumon 
gauche;    generaliza- 
tion;  Pleuresie  puru- 
lente  h  pneumoco- 
ques 


Weiss, 

Miinch.  med.  "Woch., 
1895,  p.  790 

Zwei  gleichzeitig  beo 
bachtete  Falle  von 
bosartiger  Neubil- 
dung  in  den  Lungen 
resp.  Mediastinum 
anticum 


White,  W.  Hale, 
Transact.  London 


M 


M 


23 


30 


65 


37 


LUNG    IN- 
VOLVED 


R 


Both 


CLINICAL   SYMPTOMS 


located  to  right.  Right  chest  smaller 
in  circumference  than  left.  First 
puncture,  a  little  dark  blood;  second 
"something  hke  pus." 

Tubercular  family  history.  About 
2  years  before  admission  pleuro- 
pneumonia; in  bed  5  weeks;  never 
entirely  well  since  then.  Attacks  of 
profound  dyspnoea  at  short  intervals; 
pain  in  right  chest.  6  months  before 
admission  a  tumor  was  noticed  in  right 
chest,  growing  rapidly  and  causing 
much  pain.  On  admission  loss  of 
appetite;  no  cough;  no  expectora- 
tion. Pain  in  chest;  much  oppres- 
sion. Soft  fluctuating  tumor  of  6th 
to  8th  ribs  covered  by  healthy  skin. 
Probatory  puncture  recovers  a  few 
drops  of  thick,  grayish-yellow  fluid 
containing  numerous  sarcoma  cells. 
Most  of  the  lung  had  undergone 
mucoid  degeneration;  no  tubercle 
bacilli.  Tumor  was  removed  by 
operation  and  pedicle  was  found  pro- 
jecting into  pleural  cavity.  Both 
leaves  of  the  pleura  were  adherent 
to  tumor,  allowing  it  to  be  removed 
without  opening  the  pleural  cav- 
ity. Uneventful  recovery.  Patient 
re-enters  hospital  about  6  months 
later  with  emaciation,  anorexia, 
night  sweats,  intense  dyspnoea,  haras- 
sing cough.  Almost  no  respiratory 
movement  of  right  chest;  flatness; 
rales 

Disease  commenced  with  pleurisy; 
never  well  since  then.  Intense  dysp- 
noea; pain  in  left  chest.  Spells  of 
coughing,  loss  of  flesh;  dulness  over 
left  chest;  loss  of  breathing  and  frem- 
itus. Other  organs  normal.  Tem- 
perature up  to]  104.  Profuse  night 
sweats.  Aspiration  yields  pus.  Oper- 
ation:_  very  slight  quantity  pus,  which 
contains  pneumococci  in  pure  cul- 
ture. Fever  remains  after  operation. 
Entire  clinical  picture  dominated  by 
empyema 

Always  healthy.  Much  cough;  mu- 
cous rales  over  both  lungs,  but  no 
dulness.  Rapid  loss  of  weight  and 
strength.  Continuous  high  fever. 
Small  tumor  above  left  clavicle,  others 
in  left  axilla,  right  inguinal  fold  and 
below  clavicle.  Spleen  much  enlarged 
and  hard.  Death  in  coma.  Clinical 
diagnosis:  acute  miliary  tuberculosis. 
Duration  not  quite  2  months 

Loss  of  appetite,  flesh,  and  strength. 
Pain,    dyspnoea,    dysphagia.     Aspira- 


SARCOMA 


275 


AUTOPSY    NOTES 


METASTASES 


MICROSCOPE 


Purulent, 
often 
bloody, 
no  tuber- 
cle bacilli 


wards  and  spread  out  over 
cancerous  mass  " 


Scar  infiltrated  with  tu- 
mor and  adherent  to  right 
lung.  Whole  right  lung  re- 
placed almost  entirely  by 
soft  yellowish  tumor.  Lung 
tissue  compressed  and  stud- 
ded with  tumor  nodules.  In 
centre  a  cavity  containing 
blood  and  detritus 


Bronchial 
glands  and 
resected  ribs 


Operated 
tumor  shows: 
alveolar 
structure ; 
small  round 
celled  sar- 
coma with 
mucoid  de- 
generation; 
no  epithelial 
or  giant  cells 


After  careful  search 
and  study  of  all  other 
organs,  tumor  was 
pronounced  primary 
in  lung 


No  details 


Entire  left  lung  trans- 
formed into  firm  tumor  ad- 
herent to  chest  wall 


Bronchial 
IjTnph 
nodes,  peri- 
cardium, 
right  lung, 
liver 


Medullary 
sarcoma 


Repeated 
haemop- 
tyses,    no 
tubercle 
bacilli 


Both  lungs  studded  with 
sarcoma  nodules,  especially 
left  upper  lobe,  surrounding 
bronchi  and  proliferating 
into  their  lumen 


Various 
lymph 
nodes,  liver 


Several  hse- 
moptyses 


Left  bronchus  completely 
surrounded  and  obstructed 


Left  recur- 
rent laryn- 


Round  celled 
sarcoma 


Doubtful  if  primary 
in  lung 


276 


TABLE   II 


NO. 

AUTHOR 

SEX 

AGE 

LTJNQ     IN- 
VOLVED 

CLINICAL   SYMPTOMS 

Path.    See,  Vol.    44, 

tion:    bloody  fluid  from  left  pleura. 

1893,  p.  14 

Dilated  veins  over  left  chest.     Heart 

dulness  extended  to  right.     Difference 

in  pupils.     Duration  of  disease  about 

9  months 

90 

WiLKS, 

Trans.  London  Path. 
Soc,  Vol.    IX,    1857, 
p.  31 
Fibrocelliilar  Growth  of 
the  Lung 

M 

46 

L 

Dyspnoea,  dulness  over  left  chest. 
Dropsy 

SARCOMA 


277 


No  details 


AUTOPSY   NOTES 


by  tumor;  infiltration  of  left 
upper  lobe;  portion  of  lung 
gangrenous.  Tximor  com- 
municates with  small  growth 
behind  left  sternocleido 
muscle.  Compression  of  pul- 
monary artery,  veins,  and 
aorta  by  tumor.  Aorta  and 
oesophagus  ulcerated  and 
perforated  by  gangrene 

Tumor  occupied  nearly 
whole  of  left  chest,  destroy- 
ing lower  part,  compressing 
upper  of  lung.  Root  not 
affected  but  adherent  to 
chest  wall 


METASTASES 


geal  nerve 


Posterior 
mediastinal 
glands 


MICEOSCOPE 


Fibro-sar- 
coma,  long 
nucleated 
fibres  with 
nucleated 
ceUs  inter- 
spersed, in 
some  parts 
very    rich    ii 
round  cells 


Author  remarks 
that    in     appearance 
and    behavior    it    re- 
sembles     more      the 
non-malignant  than 
the  malignant  type 


278 


TABLE    III 


Adam,  G.  R. 

Glasgow  Med.  Jour. 
1879,  pp.  31-37 


Log.  cit. 


Adams, 

London  Path.  Soc, 
1848-50,  II,  pp.  174- 
177 


Ad  AMI, 

Montreal  Med.  Jour., 
Vol.  XXIV,  1895,  p. 
510 

A    Case    of    Malignant 
Intrabronchial 
Growth  Associated 
with     a     Misleading 
Train  of  Symptoms 


AVIOLAT, 

Th^se  de  Paris,  1861 
Du  Cancer  du  Poumon. 


Bennett,  J.  Risdon, 
Intrathoracic  Growths 
London,  1872 


Bernard  et  Vermorel 
Bull,  de  la  Soc.  Anat. 
de  Paris,  1894,  pp. 
251-253 

Cancer  du  Poumon  avec 
^panchement  pleural 
sero-sanguinolent 


M 


M 


M 


25 


20 


LUNG    IN- 
VOLVED 


25 


60 


30 


36 


44 


Both 


R 


Both 


R 


CLINICAL    SYMPTOMS 


Pain  in  chest  and  dyspnoea  for  15 
months.  Dulness  from  right  apex  to 
nipple;    absence  of  breathing  sounds 


Cough,  dyspoena,  pain  in  left  chest; 
deficient  respiration;  no  vocal  frem- 
itus. Dulness  from  clavicle  to  5th  rib. 
Left  chest  half  inch  more  in  circumfer- 
ence than  right.  Later  aphonia  and 
dysphagia 


No  symptoms  until  2  weeks  before 
admission,  then  dyspncBa  and  slight 
cough;  later  cyanosis.  Small  tumor 
below  right  clavicle 


Died  4  hours  after  admission.  One 
year  before  beheved  to  have  incipient 
tuberculosis  of  right  apex.  Whole 
right  side  dull;  cavernous  breathing 
above;  feeble  breathing  below. 
Clubbed  fingers;   cyanosis 


No  heredity.  Some  pain,  dyspnoea, 
increasing  weakness.  Brain  symp- 
toms (strabismus,  headache,  formica- 
tion of  arms,  vomiting)  at  an  early 
stage.  Right  lung  normal.  Dulness 
over  left  anterior  chest  with  bronchial 
respiration.  Later  flatness  with  ab- 
sence of  voice  and  breathing 

Cough,  pain  in  left  side;  increasing 
emaciation  and  debility.  Consider- 
able scoliosis 


No  ascertainable  heredity.  For  6 
years  cough  each  winter  with  abund- 
ant expectoration.  Dates  sickness  4 
months  before  admission,  when  increas- 
ing weakness  and  dyspnoea  on  slight 
exertion.  On  admission  no  marked 
loss  of  flesh;  night  sweats.  No  lesions 
anywhere  except  on  lungs.     Left  lung 


DOUBTFUL 


279 


No  expecto- 
ration, ^ 
ounce  of 
blood  at 
late  stage 

White, 
never 
bloody 


Scant 


Yellowish, 
mucopu- 
rulent 


Not  men- 
tioned 


None;  no 
haemop- 
tysis 


Scant,    mu- 
copuru- 
lent; at 
times 
pink.    No 
tubercle 
bacilli 


AUTOPSY    NOTES 


Cancer  nodules  through- 
out entire   right   lung 


Upper  part  of  left  lung 
occupied  by  nodular  mass 
extending  up  to  thyroid, 
enclosing  aorta  and  roots  of 
cervical  vessels.  Heart  dis- 
placed to  middle  line 


Both  lungs  studded  with 
spherical,  well  demarcated 
tumors  of  all  sizes.  Upper 
cava  compressed.     No  effu 


Lobular  consolidation  at 
left  base;  purulent  bronchi- 
tis. Right  lung  adherent; 
interstitial  pneumonia  of  up 
per  lobes  and  bronchiectasis. 
No  signs  of  tuberculosis 
Right  lower  lobe  completely 
collapsed  and  adherent  to 
diaphragm.  Saccular  dila- 
tation of  left  main  bronchus 
which  is  obstructed  by  large 
soft  tumor  proliferating  up 
ward  into  the  bronchus  and 
obstructing  it 

Several  cystic  tumors  in 
the  brain.  Clear  serum  in 
left  pleura.  Upper  left  lobe 
and  its  bronchi  a  mass  of 
nodulated  tumor 


Both  pleurae  adherent. 
Right  lung  large;  left  small 
and  misshapen  on  account 
of  scoliosis.     Both  lungs 
studded  with  grayish  white 
tumors.      Both    lungs    dis- 
tinct and  diffuse  cancerous 
infiltration.     Lung  tissue 
between  infiltrated  portions 
normal 


METASTASES 


Glands  of 
thorax 


Sanguinolent  effusion  in 
right  pleura.  Lung  com- 
pressed upward.  Large  tu- 
mor in  upper  mediastinum, 
white  and  hard,  extending 
slightly  to  left,  but  main 
bulk  in  right  chest;  tumor 
has  replaced  greater  part  of 


Lymph 
nodes  of 
neck  and 
mediasti- 
num ;   both 
kidneys  and 
right  supra- 
renal 

Bronchial 
and  cervical 
lymph 
nodes  and 
liver 

Peribron- 
chial lymph 
nodes 


MICROSCOPE 


Not  given 


Not  given 


Author  calls 
it  "Fungus 
haematodes" 


Alveolar 
structure 
that  resem- 
bles carci- 
noma;   many 
cells  like  sar- 
coma 


None 


Liver 


Bronchial 
lymph 
nodes.     No 
other  metas- 
tases any- 
where 


Not  given 


No  details 


Adami    is    inclined 
to  call  it  sarcoma 


Possibly   sarcoma 


Author   simply 
states  that  the  tumor 


Not  recorded      Probably   carci- 
noma 


280 


TABLE  III 


NO. 

AUTHOR 

SEX 

AGE 

LUNG    IN- 
VOLVED 

CLINICAL    SYMPTOMS 

healthy  except  some  moist  rales.  Right 

chest  immobile  on  respiration  and  all 

signs  of  pleural  effusion.     Aspiration, 

1800  c.c.  yellow  serum.     Dyspnoea  im- 

proved but  dulness  remained  all  over 

upper  right  lung.     Tumor  of  lung  ia 

suspected  in   spite  of  good   appetite. 

lack  of  cachexia  and  non-characteristic 

sputum.     Sudden    attack    of    intense 

dyspnoea;     probatory      puncture      in 

upper  lobe  seems  to  enter  solid  tumor. 

OEdoema  of  lungs.     Death 

8 

BiBBBATTM, 

Preusa.    Vereinszeit., 
N.    F.,   V,   31,    1862 
(after  Reinhard) 

M 

25 

L 

Pain  in  left  hypochondrium ;  harass- 
ing dyspnoea;  no  cough.     Left  chest 
dilated;  some  dulness;  normal  auscul- 
tation,    ffidoema  of  feet  and  hands 

9 

BOUILLAXTD, 

Jour.  comp.  du  Die. 
des     Sciences    Med., 
1826,  Vol.  25,  p.  289 
Observations      sur      le 
Cancer  des  Poumons 

F 

29 

L 

Over  3  months  in  hospital  but  chest 
not  examined  as  patient  was  in  sur- 
gical ward.     Dry  cough,  rapid  maras- 
mus, hectic  fever.     Swelling,  supposed 
to   be   cancerous,  of   right   lachrymal 
gland 

10 

Bricheteau, 
Gaz.    des   Hopit.     de 
Paris,  1833,  VII,  p.  281 

D6gen6rescence     squir- 
rheuse   de  la  presque 
totality  d'un  Poumon 
etc. 

M 

35 

L 

When  admitted  to  hospital  was  so 
weak  he  could  not  be  examined.     Ex- 
treme   emaciation;     high    fever;     en- 
larged    left     axillary     glands.     Hard 
tumor     over     left     clavicle.     Dulness 
over    left    chest.     Clinical    diagnosis: 
acute  phthisis 

11 

BUDD, 

London  Medico-Chir. 
Trans.,      1859,     Vol. 
XLII,  p.  215 
On  Some  of  the  Effects 
of  Primary  Cancerous 
Tumors    within    the 
Chest 

M 

31 

R 

Good  health  until  attack  of   pneu- 
monia in  right  lower  lobe;   since  then 
short  breathing;    later  pain  in  lower, 
right  chest.     Gradual  loss  of  strength, 
cough,  dulness  and  inaudible  respira- 
tory murmur  over  lower  right  chest. 
Later  cedcema  of  right  chest  and  face; 
enlargement  of  superficial  veins;  fric- 
tion   over    precordial    region;    intense 
dyspnoea;  purpuric  spots.     Enormous 
enlargement  of  veins  over  right  chest 
and  belly.     Duration  of  disease  about 
2  years 

12 

Loc.  CIT. 

M 

20 

R 

Always  well.     After  a  cold,  pain  in 
right  chest  posteriorly,  later  anteriorly. 
After  a  week  well,   then  cedcematous. 
Dilatation  of  veins    of   chest  and  epi- 
gastrium.    Dyspnoea,    hoarseness, 
cough ;  later  vomiting.     Fever,  intense 
dyspnoea;   death.     Duration   about   6 
months 

DOUBTFUL 


281 


Frothy  mu 
cus  tinged 
with 
blood. 
Later 
greenish 
pus 


AUTOPSY    NOTES 


right  upper  lobe  and  envel- 
ops origin  of  anterior  me- 
diastinum, trachea,  arch  of 
aorta,  and  both  pneumogas- 
trics,  proliferating  slightly 
into  trachea  at  bifurcation. 
Left  lung  healthy 


Entire  left  lung  converted 
into  medullary  tumor  except 
small  portion  at  apex. 
Pleura  adherent.     Right 
lung  displaced 

Upper  left  lobe  almost 
completely    converted    into 
whitish  tumor.     No  ulcera- 
tion;  no  cavity.     "Cancer- 
ous polypi"  in  posterior 
nares 

Right  lung  normal.  En- 
tire left  lung  transformed 
into  a  hard,  bluish,  marbled 
tumor  showing  no  remnants 
of  pulmonary  structure;  no 
softening,  no  suppuration, 
no  ulceration.  Tumor  ad- 
herent to  pleura  in  upper 
portion.  Yellow  serum  in 
pleura.  All  other  organs 
normal 

Lower  part  of  right  chest 
occupied  by  a  white  can- 
cerous mass;  extending  to 
mediastinum;  tip  on  level 
with  clavicle.  Penetrates 
upper  cava,  projects  into 
right  auricle  enclosing  root 
of  lung.  Large  bronchi  pen- 
etrated by  tumor  and  nar- 
rowed but  not  closed. 
Large  bronchiectatic  cavity 
filled  with  pus  in  upper  lobe 
Pericarditis 

Firm,  nodular,  yellowish 
white  tumor  in  mediastinum, 
penetrating  into  right  lung. 
Upper  cava,  right  innom- 
inate vein  and  part  of  left 
involved  in  tumor,  which 
also  projects  into  pericar- 
dium. Tumor  penetrates 
trachea  ^  inch  above  bifur- 
cation and  down  right  main 
bronchus.  Small  nodule  in 
left  bronchus 


METASTASES 


Right  lung 
and  liver 


No  others 


None 


No  others 
mentioned 


Bronchial 
and  tracheal 
glands 


MICROSCOPE 


Not  men- 
tioned 


Not  given 


Not  given 


No  details 


None  given 


Probably    sarcoma 


Probably  sarcoma 


Doubtful  whether 
bronchial  carcinoma 
or    sarcoma 


Probably  primary 
in  mediastinum  and 
sarcoma 


282 


TABLE   III 


13 


14 


15 


16 


17 


Bttdd, 
Loc.  cit. 


BUREAIT, 

Bull,  de  la  Soc.  Anat. 
de  Paris,  V,  Serie  10, 
1896,  p.  26 
Tumeur  de  hile  du  Pou- 
mon  droit.  Pleuresie 
droit 


BlTRROWS, 

Med.  Chirurg.  Trans., 

1844 


Cannstatt, 

Hannover.  Annalen 
fiir  die  gesammte 
Heilkunde,  Vol.  V, 
..  1840,  p.  433 
Ahren-lese  au3  der 
Praxis 

Chahteris,  M. 

Lancet,    1874,    I,    p. 

126 
On  Intrathoracic  Cancer 


M 


M 


M 


63 


68 


20 


22 


44 


LUNG    IN- 
VOLVED 

R 


R 


R 


Both 


CLINICAL    SYMPTOMS 


Always  well.  Illness  commenced  with 
cough,  shortness  of  breath.  3  weeks 
before  admission  swelling  of  face;  no 
pain.  Dulness  and  diminished  voice 
and  breathing  over  greater  part  right 
chest  in  front.  Heart  sounds  are  heard 
loud  over  the  dull  area  of  right  chest. 
Dilated  veins  over  chest  on  both  sides. 
Increasing  oedcema  of  chest,  face,  and 
arms.  Intense  dyspnoea.  Death  from 
asphyxia.     Duration  about  7  months 

For  some  years  always  aware  of 
some  trouble  in  chest.  Frequent 
attacks  of  bronchitis  and  strong  op- 
pression on  climbing  or  walking 
briskly.  No  palpitation,  but  violent 
pains  behind  sternum.  Diagnosis  of 
angina  pectoris  was  made,  for  which 
she  was  treated  in  hospital.  Improved 
and  for  some  years  the  attacks  of  pain 
and  oppression  disappeared  entirely. 
A  few  days  before  admission  to  the 
hospital  while  on  train  to  Paris,  sudden 
chill  and  violent  pain  in  right  chest. 
On  admission  flatness  at  the  right  base, 
loss  of  fremitus,  faint  distant  breath- 
ing. All  other  organs  normal.  No 
cyanosis,  no  oedcema ;  no  cardiac  symp- 
toms. Later  slight  rise  of  temperature. 
Aspiration  dark  yellow  serum.  Rapid 
refilling  of  chest.  Three  punctures  with 
increasing  amount  of  serum.  Notwith- 
standing punctures  dyspnoea  increases 
to  most  intense  orthopnoea.  Suddenly 
hsemopytsis  and  death.  Duration  of 
the  acute  stage  only  a  few  months 

First  symptoms  6  months  before  ad- 
mission, then  pain  under  sternum, cough 
and  loss  of  appetite.  Better  for  a  time, 
then  dyspnoea,  emaciation,  and  sweat- 
ing. Dulness  on  upper  right  chest,  in- 
creasing to  flatness.  Feeble  bronchial 
respiration.  CEdcema  of  face,  right 
hand,  and  arm.  Duration  of  disease 
a  little  more  than  6  months 

Profuse  hsemoptyses.     No  pain. 
Dulness  over  left  chest;    pectoriloquy 


For  3  months  hoarseness,  vomiting  of 
food  and  blood ;  loss  of  weight,  increas- 
ing weakness.  On  admission  cough, 
dyspnoea,  dysphagia,  persistent  vomit- 
ing. Rales  all  over  chest.  Posteriorly 
dulness  at  angle  of  right  scapula.  Par- 
alysis of  left  vocal  cord.  Death  after 
increasing  dyspnoea  and  weakness 


DOUBTFUL 


283 


SPUTUM 

AUTOPSY   NOTES 

METASTASES 

MICROSCOPE 

BEMABKS 

Bloody; 
profuse 
hajmor- 
rhage 

Serous  fluid  in  right  pleura. 
Whole  of  right  upper  lobe 
converted  into  solid   white 
tumor  included  in  enormous- 
ly thickened  pleura.    Below 
right  main  bronchus  a  scir- 
rhous mass,  size  of  a  small 
apple  invading  but  not  con- 
stricting    bronchus,      com- 
pressing  upper  cava.     Few 
nodules  in  left  upper  lobe 

Left  lung 
bronchial 
glands 

None 

Origin  probably  in 
bronchial  glands. 
Possibly  sarcoma,  but 
probably  bronchial 
carcinoma 

Haemopty- 
sis 

Abundant   fluid   in   right 
chest.     White,     very    hard 
tumor  at  root  of  right  lung 
adherent  to  pericardium. 
The  lung  is  of  the  size  of  2 
fists,  and  the  tumor  starting 
from    the    hilus    penetrates 
deeply  into  the  lung  tissue. 
Right  main  bronchus  com- 
pletely obstructed 

Tracheal 
and  bron- 
chial lymph 
nodes 

None  given 

Difficult  to  say 
whether  we  have  to 
deal  here  with  sar- 
coma or  carcinoma. 
It  is  probably  carci- 
noma 

Haemopty- 
sis and 
currant 
jell5'  ex- 
pectora- 
tion 

Right  chest  larger  than 
left.     2000  c.c.  brown  fluid 
in  right  pleura._   White,  lob- 
ulated  tumor  in  lower  and 
middle    lobes.      Bronchiec- 
tatic  abscesses.  Compression 
of   right   pulmonary   veins, 
right   carotid,  and   internal 
carotid 

Cervical, 
axillary,  and 
mediastinal 
lymph 
nodes 

None  given 

Author  calls  the 
growth  cancer.  It  is 
probably  sarcoma 

Profuse, 
foul,  pu- 
trid. 
Profuse 
haemop- 
tysea 

In  left  lung  cavity  larger 
than  man's   fist,    the   walls 
of  which  are  thickened  and 
made  up  of  scirrhous  mate- 
rial 

Bronchial 
glands 

Not  men- 
tioned 

Foamy, 
abundant 

Tumor    at    bifurcation 
branching   into    bronchi   of 
both  lungs,  especially  right. 
Involvement  and  compres- 
sion of  oesophagus.    Left  re- 
current   laryngeal    also    in- 
volved 

Not  men- 
tioned 

Numerous 
round  cells 
surrounded 
by  vascular 
connective 
tissue 

Probably  Barcoma. 
LA. 

284 


TABLE   III 


18 


19 


20 


21 


22 


Clark,  A. 
Lancet,  1856 


Cockle, 
Association   Med. 
Jour.,  London,  1854, 
p.  990 

De  Boter,  H. 

Le  Progres.  Med.,  Ill, 

1875,  p.  87 
Adenopathie    bron- 

chique  Cancereuse 


De  Renzi, 

La     Riforma      Med 

Napoli,    XIV,    1898, 

Vol.  I,  p.  747 
Un  Caso  di  Carcinome 

del  Polmone 


De  Valcourt, 
Revue   Med.,  Ill, 
XVIII,  1874,  723 
Press.     Med.     Beige, 
Bruxelles,  1874,  Ann. 
26,  p.  406 

Cancer   pulmonaire, 
compression,  etc. 


M 


M 


M 


M 


22 


64 


25 


55 


25 


LTJNG    IN- 
VOLVED 


R 


Both 


Both 


R 


CLINICAL    SYMPTOMS 


Clinical  signs  of  pulmonary  phthisis. 
Night  sweats;    diarrhoea 


Laryngeal  cough,  hoarseness,  dysp- 
noea, dysphagia,  fever.  Follicular 
affection  of  throat.     No  signs  on  lungs 


Testicle  removed  for  suppuration 
two  years  before  admission;  thereafter 
legs  became  swollen  and  painful;  dysp- 
noea on  walking;  chronic  bronchitis. 
Loss  of  weight  and  strength,  hoarseness, 
night  sweats.  Examination  on  admis- 
sion revealed  a  hard  gland,  size  of  a  hazel 
nut,  in  left  supraclavicular  region.  Dul- 
ness  over  sternum  and  posteriorly  be- 
tween scapulae.  On  right  side  anteriorly, 
distinct  murmur-like  sounds  simulating 
aneurysm,  also  faint  rales.  Over  area 
corresponding  to  tracheal  bifurcation 
bronchial  breathing.  Cough  character- 
ized by  whoop.  Dysphagia,  aphonia, 
slight  albuminuria.  Death  during  an  at- 
tack of  dyspnoea  13  days  after  admis- 
sion, glands  having  rapidly  increased  in 
size.  Diagnosis:  tuberculosis  of  bron- 
chial glands 

For  2  years  cough;  8  months  pain  in 
left  shoiilder  (patient  was  accustomed 
to  carrying  heavy  loads  on  left  shoulder 
and  continued  to  do  it  notwithstanding 
the  pain).  For  3  months  hoarseness, 
loss  of  strength  and  weight,  harassing 
cough.  On  admission  left  supra-  and 
infra-clavicular  fossse  are  abolished  and 
bulging  so  that  left  clavicle  is  hardly 
visible.  Bulging  occupies  nearly  all  of 
left  shoulder  and  supraspinous  region, 
extending  down  to  interscapular  space 
to  left  of  vertebral  column.  Over  all 
the  swollen  region  dilated  superficial 
veins,  impaired  respiratory  motion. 
Dulness  and  diminished  respiration 
and  fremitus  over  all  this  region.  Left 
supraclavicular,  axillary,  and  inguinal 
glands  enlarged.  No  fever.  Paralysis 
of  left  recurrent  laryngeal.  Intense 
pain  from  left  shoulder  through  arm. 
Blood  examination  showed  very 
moderate  secondary  anaemia;  no  leu- 
cocytosis.     All  other  organs  healthy 

Dyspnoea,  cachexia,  complete  apho- 
nia, cyanosis,  dysphagia.  Left  thorax 
depressed,  right  increased  in  volume; 
dulness  throughout;  diminished  breath- 
ing.    Tracheotomy  to  relieve  dyspnoea 


DOUBTFUL 


285 


Haemopty- 
sis 


Purulent, 
blood- 
stained 


Foamy, 
mucous, 
streaked 
with 
blood 


AUTOPSY    NOTES 


Scant,    mu- 
copuru- 
lent, con- 
tains no 
tubercle 
bacilli 


Mucoid 


Tumor  in  upper  part  right 
lung    extending    into    lung 
from    periphery.     Bronchi 
filled  with  cancer  cells 

Both  lungs  studded  with 
nodules.  Softening  and  cav' 
ity  in  upper  left  lobe.  Su- 
perficial ulcer  in  larynx 

Both  lungs  medullary 
nodules;  at  base  of  both 
lungs  small  subpleural  nod- 
ules. Bronchial  glands  en- 
larged and  fill  entire  medi- 
astinum, compressing  aorta, 
thoracic  duct,  vena  cava 


METASTASES 


No  details  given.     Stated 
'Diagnosis  confirmed" 


Enormous  right  lung  that 
had  dislocated  heart  to- 
ward left.  Right  lung  lar- 
daceous,  semi-transparent, 
and  hard.  Compression 
right  bronchus 


Not  men- 
tioned 


Mediasti- 
nal lymph 
nodes 


Liver,  ret 
roperitoneal 
glands;  bal 
ance  men- 
tioned under 
autopsy 


MICBOSCOPE 


No  details 


Liver,  tra- 
cheal and 
bronchial 
lymph 
nodes 


Not  men- 
tioned 


No  details 


Not  given 


Possibly   sarcoma 


(?) 


Tumor  is  called  en- 
cephaloid  cancer 


No  details 


Not  given 


Possibly  sarcoma 


286 


TABLE   III 


NO. 

ATJTHOB 

S£X 

AGE 

LUNG    IN- 
VOLVED 

CLINICAL   SYMPTOMS 

23 

DOMBROWSKI, 

Jahresbericht    der 
Schles.  Gesellsch.  fiir 
Vaterl.    Cult.,     1901. 
Breslau,  1902,  p.  115 
Ein  Fall  von  Tximor  der 
linken  Lunge 

F 

50 

L 

Always  weU  until  one  month  before 
admission,  then  pain  in  left  chest, 
cough,  dyspncsa.  Impaired  respiration 
left  upper  chest;  bulging  left  supra- 
clavicular region.  Left  breast  larger 
than  right;  small  hard  glands  in  both 
axillae.  Dulness  descends  from  above 
left  clavicle,  merges  into  heart 
dulness,  extends  into  axilla  and 
posteriorly  to  4th  thoracic  vertebra. 
Absence  of  breathing  over  dull  area; 
later  faint  vesicular  breathing.  X-ray 
showed  deep  shadow  over  left  upper 
lobe.  Clinical  diagnosis:  tumor  of 
left  lung 

24 

Elliot, 

British  Med.  Jour., 
April,  1874 

F 

28 

R 

Pain  in  right  chest;  complete  flat- 
ness; absence  of  breathing,  dyspnoea, 
harassing  cough.     Duration  7  months 

25 

Fagqe, 

Trans.  London  Path. 

Soc,     1867,     XVIII, 

pp. 29-31 
Disseminated    Primary 

Cancer  of  Lungs 

M 

50 

Both 

Orthopnoea,  cough,  debiHty.  Dul- 
ness, slight  bronchophony  and  sibilant 
rgiles  at  base  of  each  lung  posteriorly, 
especially  left.  CEdoema  of  legs.  Sud- 
den death 

26 

FUCHS, 

Diss.     Miinchen, 
Beitrage    zur  Kennt- 
niss  der    primaren 
Geschwtilstbildungen 
in  der  Lunge 

F 

83 

L 

No  clinical  history 

27 

LOC.  GIT. 

F 

56 

R 

Diagnosed  during  life  as  pleurisy 
and  later  as  empyema 

28 

Gat, 

Boston  Med.  &  Surg. 
Jour.  Vol.  94,  p.  6 
Encephaloid  Cancer  of 
Lungs 

M 

57 

L 

Difficulty  in  respiration,  cough,  in- 
creasing dyspnoea.  Loss  of  strength. 
Pain  in  region  of  liver.  Cough  sub- 
sides; dyspnoea  increases.  Dulness 
over  left  base  increasing  to  flatness 
all  over  left  chest  except  at  apex. 
Aspiration,  at  first  clear  yellow  fluid; 
later  bloody.  Duration  of  disease 
about  one  year 

29 

Gordon, 

Dublin  Hospital  Gaz. 

1854-5,  I,  94 
Malignant    Tumor     in 

Apex  of  Right  Lung 

M 

32 

R 

Cough,  pain  in  right  chest,  cyanosis, 
dyspnoea.  Dulness  and  feeble  breath- 
ing over  right  apex.  Later  swollen 
glands  above  clavicle.  Paralysis  and 
oedcema  of  right  hand.  Right  side  of 
face  swollen.  Purpuric  spots  fol- 
lowed by  gangrene  in  cEdoematoua 
portion.     Duration    about   4    years 

DOUBTFUL 


287 


AUTOPSY    NOTE3 


METASTASES 


MICROSCOPE 


Bloody, 
raspberry 
jelly;   no 
tubercle 
bacilli 


None 


No  details 


Not  given 


Fluid  in  right  pleura.  Al- 
most entire  right  lung  con- 
verted into  "cancer" 


Small    node 
in  right  au- 
ricle and 
aorta 


Clear  brown  fluid  in  both      Pericar 
pleurae.  Both  lungs  studded  jdium,    right 
with  cancerous  deposits  re-  auricle,    left 


sembUng  tubercles 


Clear  serum  in  left  pleura. 
In  left  upper  lobe  a  softened, 
difl'usely    infiltrated    area 
filled  with  greenish  matter 


Fibrinous  exudate  in  right 
pleura.  Greater  part  of  up- 
per right  lobe  converted  into 
a  soft  lardaceous  tumor 


Both  lungs 
and    pleura 
bronchial 
lymph 
nodes,  and 
liver 

Sanguinolent  fluid  in  left    Bronchial 
chest.  Lung  compressed  up-  lymph 
ward  and  backward.  Entire  nodes,  both 
pleural    surface    infiltrated  lungs,    kid- 
with     encephaloid     cancer,  neys 
Left   lung    filled  vsdth    nod- 
ules;   nodules  also  in  right 
lung.      Cancerous     infiltra- 
tion of  pleural  lymphatics 

_  Small  primary  tumor  in    Subclavian 
right  apex.     Obliteration  of  Ij^mphatic 
subclavian   vein;     compres- nodes,  liver 
sion  of  axillary  artery  and 
brachial   plexus 


ventricle, 
Hver 


None 


No  details 


No  details 


Author  says 
soft  area  is  a 
cancerous  in- 
filtration, 
consisting  of 
spindle  cells 
and  large 
round  epithe- 
lioid cells 

Not  given 


No  data 
given.      Sim- 
ply called  en- 
cephaloid can 
cer 


No  data  given 


Doubtful    whether 
carcinoma  or  sarcoma 


Probably  sarcoma 


Possibly  sarcoma 


Primary  seat  of 
neoplasm  probably  in 
pleura 


288 


TABLE   III 


^u. 

AUTHOR 

SEX 

AGE 

VOLVED 

CLINICAL    SYMPTOMS 

30 

Graves, 

London  New  Syden- 
ham Soc,  2d  Edition, 
Vol.  2,  p.  70 

Clinical  Lectures  on  the 
Practice  of  Medicine 

M 

36 

R 

Pain  in  right  chest,  cough,  dyspncea, 
hoarseness.  Later  oedoema  of  face  and 
neck;  dilated  veins.  Dulness  and 
tracheal  respiration.  Impaired  mo- 
bility over  all  of  right  chest;  no  rales. 
Left  chest  normal.  Heart  sounds 
heard  very  distinctly  over  posterior 
aspect  of  right  chest.  Enlarged  liver, 
jaundice;  dysphagia,  increasing  dysp- 
noea and  CEdcema.  Secondary  tumors 
on  lower  jaw,  forehead,  and  near  lum- 
bar spine 

31 

Green, 

Lancet,   1898,   II,   p. 
1705 

F 

14 

L 

Debility,  dyspnoea,  signs  of  consoli- 
dation of  left  lung  and  effusion  into 
pleura.  Enlarged  glands  above  right 
clavicle 

32 

Greenwood, 

British    Med.     Jour., 
1897,  II,  p.  1337 

A   Case   of   Pulmonary 
Carcinoma 

F 

49 

R 

For  several  weeks  cough,  dyspncea, 
swelling  of  face  and  neck.  Hardly 
any  air  in  right  apex;  tubular  breath- 
ing left  base  in  front.  Improved  for 
a  short  time,  then  increasing  dyspncea 
and  cough,  pain  down  spine.  Shortly 
before  death  tubular  breathing  right 
base;  cedcema  both  legs.  Duration  a 
little  over  6  months 

33 

Griffiths, 

Brit.  Med.  Jour.,  1888, 

I,  p.  647 
Sarcoma  of  the  Lung 

M 

58 

L 

Cough,  emaciation,  cyanosis,  oedoe- 
ma of  eyehds,  dyspnoea.  Absolute  dul- 
ness, feeble  motion  and  respiration  over 
left  chest.  Aspiration  negative.  Diag- 
nosis of  malignant  tumor  of  lung  made 
during  Hfe.     Duration  about  one  year 

34 

Hafner, 

Med.  Centralblatt, 
38,  1852 

M 

20 

R 

Cachexia,  tumor  of  right  clavicle; 
paralysis  of  right  arm;  radial  pulse 
smaller  on  right  than  on  left  side. 
Dyspnoea,  pain,  dry  cough,  hoarseness, 
dulness  over  upper  portion  of  right 
chest;    dilated  veins  of  neck  and  arm 

35 

Hanot, 

Arch.    gen.  de  Med., 
1877,  Vol.  I,  Ser.   6, 
p.  29 

Cancer  primitif  du  Pou- 
mon  et  du  Mediastin 
chez  une  femme  de  78 
ana 

F 

78 

L 

Always  well.  Dry  cough  for  long 
time,  worse  for  last  few  months; 
dyspnoea,  pain  in  right  chest.  Alter- 
nating diarrhoea  and  constipation.  On 
admission  cachexia,  weakness,  dulness 
over  whole  of  left  chest.  In  upper 
portion  distant  breathing  sounds;  in- 
creased vocal  fremitus;  subcrepitant 
rales.  At  base  of  right  lung  rales  and 
some  friction  with  slight  dulness. 
Heart  pushed  to  the  right.  Later, 
oedcema  of  feet,  dysphagia,  delirium. 
Death  from  exhaustion  about  3  weeks 
after  admission 

DOUBTFUL 


289 


Scant,  mU' 
coid, later 
bloody- 


Not  given 


Purulent, 
blood- 
stained 


Mucopuru 
lent.     No 
bacilli 


No  details 


No  details 


AUTOPSY    NOTES 


Left  lung  normal;  right 
lung  a  solid  tumor  with  thin 
shell  of  lung  tissue  outside 
Tumor  contains  some  cysts 


Entire  left  lung  trans- 
formed into  tumor,  prob- 
ably starting  from  hilus. 
Entire  mediastinum  filled 
with  tumor;  imbedded  aor- 
tic arch  and  large  vessels 

Tumor  size  of  cocoanut 
occupying  middle  and  pos- 
terior mediastinum  and  ex- 
tending along  root  into  right 
lung.  All  other  organs 
healthy 


Tumor  at  root  of  left  lung 
extending  along  bronchi  and 
larger  vessels,  surrounds  and 
compresses  aorta,  pulmon- 
ary vessels,  and  oesophagus. 
Compression  of  left  main 
bronchus 

Effusion  in  right  pleura; 
hard  lobular  tumor  in  upper 
part  right  lung.  Compres- 
sion of  trachea  and  superior 
cava 


Left  pleural  cavity  filled 
with  yellow  serous  fluid; 
lungs  compressed;  pleura 
red,  thickened.  Posterior 
mediastinum  filled  with 
large,  hard,  white  tumor 
containing  several  soft,  al- 
most fluctuating  foci.  Nod- 
ules as  large  as  a  pigeon's 
egg  on  trachea,  directly  un- 
der aorta;  another  mass 
under  root  of  lung.  (Esoph- 
agus compressed  and  adher- 
ent to  tumor.  Root  of  left 
lung  surrounded  by  tumor; 
bronchus  not  compressed. 
Tumor  in  left  lung  consist- 
ing of  6  nodules  extending 
downward  and  outward  to 


METASTASES 


Mediasti- 
nal and 
mesenteric 
lymph 
nodes,  lower 
jaw,   cranial 
bones,     and 
some  verte- 
brae 


Not  given 


Not  given 


None 


Pleura, 
bronchial 
glands.     No 
others 


MICEOSCOPE 


No  data  given 


No  data  given 


Not  given 


Not  given 


Alveolar 
structure 
with  polyg- 
onal cells 


As  no  microscopic 
data   are  given  it  is 
difficult  to  tell 
whether    sarcoma    or 
carcinoma 


Probably    sarcoma 


Possibly  carcinoma 


20 


290 


TABLE   III 


36 


37 


38 


Harbitz, 

Norsk  Mag.  f.  Lae- 
gevidenskaben,  etc., 
1903,  Bd.  1,  p.  727 


Harris, 

Intrathoracic 
Growths.     St.  Bar- 
tholomew's Hosp.  He 
ports.  Vol.  28,   1892, 
p.  73 

Heschl, 

Wiener     Med.     Wo- 
chenschr.,    1877,   No 

..  17,  p.  385 

Uber     ein     Cylindrom 
der  Lunge 


39 


M 


M 


Hetpelder, 

Arch.    gen.    de    Med. 

14,    2d    S6rie,    1837, 

p.  345 
DuCancer  des  Poumons 


LUNG    IN- 
VOLVED 


45 


68 


72 


M 


R 


24 


CLINICAL    SYMPTOMS 


Sick  since  childhood;  more  or  less 
cough.  Gradual  increase  of  cough 
and  dyspnoea.  Pain  in  right  chest. 
Lymphatic  glands  of  neck  swollen. 
Sonorous  percussion  sounds  over  both 
lungs.  Prolonged  expiration  in  front 
and  behind 


Pain  in  left  chest;  dry  cough,  in- 
creasing dyspnoea  and  emaciation. 
Bulging  of  left  chest ;  absence  of  fremi- 
tus; displacement  of  heart  to  right. 
Aspiration  24  ounces.  Pleura  opened; 
foul  discharge  for  a  month.      Death 

No  clinical  history 


Always  well.  Attack  of  pleurisy 
that  yielded  to  treatment.  Later 
inflammatory  symptoms  in  chest  — 
pain,  dry  cough.  Left  chest  immov- 
able on  respiration  and  dilated.  Dul- 
ness;  no  voice  or  breathing;  no  heart 
sounds,  right  chest  normal.  Later 
large,  hard,  nodulated  tumor  on 
anterior  surface  of  left  chest.  Cyano- 
sis; dyspnoea.  Still  later  nodulated 
tumors  on  left  clavicle,  swelling  of 
axillary  glands;    general  dropsy 


DOUBTFUL 


291 


AUTOPSY    NOTES 


smaller  nodules.  Left  lower 
lobe  catarrhal,  colloid  pneu- 
monia. Right  lung  soft  and 
congested 

Bloody  fluid  in  pericardial 
cavity  with  beginning  mu- 
copurulent inflammation  of 
pericardium.  In  posterior 
mediastinum  enlarged  lym- 
phatic glands,  also  hard, 
grayish,  degenerating  tu- 
mor. Bronchial  glands  and 
glands  at  root  of  lung  en- 
larged. Tumor  formation 
bronchial  mucous  mem- 
brane. Lungs  emphysemat- 
ous but  otherwise  normal 

No  autopsy 


2000  CO.  clear  serum  in 
right  chest.  Tumor  occu 
pying  almost  entire  right 
lower  lobe;  only  small  border 
of  compressed  lung  tissue  on 
upper  periphery  of  tumor 
Tumor  made  up  of  soft  and 
very  hard  and  cartilaginous 
nodules 


Numerous  tumors  on  wall 
of  left  chest.  Left  lung  en- 
tirely transformed  into  one 
large  tumor  in  which  neither 
vessels  nor  bronchi  can 
be  recognized.  Left  main 
bronchus  obliterated.  Pul- 
monary artery  and  vein  ob- 
literated, also  left  pleura. 
Superficial  tumors  commun- 
icate with  internal  tumors 
through  intercostal  spaces 


METASTASES 


Mediasti- 
nal and 
bronchial 


None 


Besides 
the   axillarj' 
glands  and 
superficial 
tumors  on 
chest,  no 
other  metas- 
tases 


MICBOSCOPB 


Lympho- 
sarcoma with 
alveoli 
clothed  with 
polygonal 
and  polsonor- 
phous  epithe- 
lial cells 


Superior  and 
anterior  nod- 
ules consist  of 
round  and 
spindle  cells 
with  abun- 
dant hyper- 
trophic elastic 
fibres.     Pos- 
teriorly nod 
ules  contain 
several  con- 
cretions   and 
some  plate- 
lets of  genu- 
ine bone, 
masses  of 
elastic    tissue 
between 
round  and 
spindle  cells 
and  many  pe- 
culiar colloid 
forms  of  vari- 
ous shapes 

No  details 


Probably  carci- 
noma of  left  lung  and 
pleura 


Should   be   classed 
under  sarcoma  group 


Probably  sarcoma 


292 


TABLE  III 


40 


41 


42 


43 


44 


HODENPTL, 

Proceedings     N.     Y 
Path.  Soc,  1895,  p.  19 
New    Growths    of    the 
Lung,    Mediastinal 
and  Mesenteric 
-Glands,  Liver  and 
Stomach 


Hope,  J. 

London,   1834,  p.  45 
Principles  and  Illustra- 
tions of  Morbid  Anat 
omy  . 


Janewat, 

Medical  Record,  1883, 

p.  215 
Primary  Sarcoma  of 

Lung 


Jakobsohn, 

Deutsch.   Med.  Zeit- 
schr.,  1897,  p.  487 

Sarkom  der  Lungen 


Jennings, 

Proceedings  Path. 
Soc.  of  Dublin,  1867- 
68,  p.  291 


M 


M 


M 


M 


M 


43 


25 


56 


46 


42 


LUNG    IN- 
VOLVED 


R 


R 


Both 


clinical  symptoms 


Fell  on  left  shoulder;  soon  there- 
after lancinating  pain  in  left  chest. 
Pleuritic  effusion  of  bloody  serum; 
numerous  tappings.  Dulness  over 
left  chest  in  front  and  behind  with 
absolute  flatness  and  abolished  voice 
and  breathing  in  lower  portion.  Aspi- 
ration does  not  afford  relief.  Dyspnoea 
and  suffocation,  csdcema  of  left  arm; 
anasarca  and  ascites.  Duration  about 
7  months 


10  years  before  admission  strain  at 
cricket;  ever  since  tenderness  on 
right  chest.  On  admission  tumor  of 
right  chest  extending  from  4th  to  11th 
rib;  imperfect  expansion  of  right 
chest;  absolute  flatness  and  absence 
of  breathing  sounds  below  5th  rib. 
Death  10  days  after  admission. 
External  tumor  noticed  18  months 
before  admission 

Progressive  debility,  dyspnoea,  slight 
fever,  pain  in  right  side,  dyspnoea. 
Flatness  over  half  of  right  lung; 
diminished  fremitus.  Small  quantity 
bloody  fluid  in  pleura 


Syphilis  admitted.  While  carrying 
a  heavy  load  of  zinc  plates  on  shoulder 
up  a  ladder,  suddenly  severe  cough  and 
dyspnoea,  with  much  rattling  and 
wheezing.  Was  carried  home  and 
since  that  time  intense  dyspnoea,  im- 
paired respiratory  motion  left  chest; 
dulness  over  left  chest  and  bronchial 
respiration.  Within  next  week  dul- 
ness becomes  more  intense  and  exten- 
sive. Some  improvement  after  10 
mercurial  inunctions ;  respiration  more 
normal  and  patient  in  every  way  much 
better.  Probatory  puncture  made 
and  needle  penetrates  deeply  into  hard 
mass.  (Not  stated  where  puncture 
was  made.)  A  few  drops  of  milky, 
easily  coagulating  fluid  withdrawn  in 
syringe.  This  under  the  microscope 
shows  numerous  small  round  and 
spindle  cells.  Since  then  patient  feels 
fairly  well,  but  has  attacks  of  suffoca- 
tion from  time  to  time 

Well  until  close  of  year,  then  intense 
dyspnoea,  cough,  slight  expectoration. 
Pain  in  right  chest;  stridulous  respi- 
ration. Dulness  over  right  chest; 
absence  of  voice  and  breathing,  except 
coarse  tubular  breathing  in  scapular 


DOUBTFUL 


293 


Bloody 


AUTOPSY    NOTES 


Scant, 
grayish 


Not  bloody 


No  details 


Thin  and 

scanty. 
No  haem- 
optysis 


Left  lung  almost  entirely 
converted  into  a  mass  of 
new  growth.  Enormously 
enlarged  mediastinal  glands 
compressing  trachea  and 
oesophagus.  Large  mass 
above  heart,  encircling  large 
vessels.  Fracture  of  a  rib 
with  much  callus 


Tumor  fills  entire  right 
pleural  cavity  except  |  of 
upper  lobe.  Lower  lobe 
flattened  and  "inextricably 
confused  with  the  tumor." 
Heart  dislocated  to  left.  8th 
and  9th  ribs  destroyed  by 
tumor,  and  through  this 
space  tumor  emerges  from 
chest 

Neoplasm  in  middle  and 
lower  lobe  of  right  lung 


METASTASES 


Anterior  mediastinum 
and  anterior  superior  sur- 
face of  lungs  occupied  by  tu- 
mor which  absorbed  part  of 
thoracic  wall  and  formed 
part  of  tumor  visible  during 


Liver, 
lymph 
nodes,  and 
cardiac  end 
of  stomach; 
ulcerated 
nodule  in 
stomach 


Upper  right 
lobe  and  left 
lung 


MICROSCOPE 


Tracheal, 
bronchial 
and  medias- 
tinal lymph 
nodes;  liver 


Mediasti- 
nal and  ab- 
dominal 
glands;  liver 


Typical  car- 
cinoma in 
lung  with 
well-marked 
alveolar  struc 
ture  and   epi- 
thelial cells. 
In  IjTnph 
nodes  and 
liver  alveolar 
structure  but 
spindle  cells 

No  details 


Probably  carci- 
noma of  lung 


Insufficient 


No  details 


Probably    primary 
sarcoma  of  right  lung 


In  extract  neo- 
plasm is  called  "in- 
filtrating cancer," 
and  description  tal- 
lies with  usual  forms 
of  infiltrating  carci- 
noma. In  title  the 
tumor  is  called  sar- 
coma 

Author  diagnoses 
sarcoma    and    thinks 
it  sarcoma   of  pleura 


294 


TABLE  III 


45 


46 


47 


48 


49 


Kempeh, 

Trans.  Indiana  Med. 

Soc,  1882,  172-178 
Primary  Cancer  of 

Lung 

KOEYLINSKI, 

Diss.   Greifswald, 
1904 
Uber      primare      Sar- 
kome  in  der  Lunge 


KUHN, 

..  Diss.   Zurich,   1904 
Uber  maligne  Lungen- 
geschwulste 


Langb,  J.  C. 

Penna.     Med.     Jour. 

Pittsburg,    1903-4, 

Vol.  XXXIII,  p.  202 
Four   Cases    of    Malig 

nant   Disease   of  the 

Lungs 


Langstaff, 

Medico-Chir.  Trans., 
Vol.  IX,  1818,  p.  295ff 

Cases  of  Fungus  Hae- 
matodes,  Cancer,  and 
Tuberculated  Sar- 
coma with  Observa- 
tions 

60  Lataste, 

Bull,  de  la  Soc.  Anat 
3  S.,  X,  p.  767  (after 
Szelowski) 
Cancer  primitif  du  Pou 
mon,  etc. 


M 


M 


M 


LUNG    IN- 
VOLVED 


M 


46 


75 


50 


31 


30 


47 


R 


R 


L(?) 


CLINICAL    SYMPTOMS 


region.  Left  side  normal.  Heart 
much  more  audible  on  right  than  on 
left  side.  Impaired  mobility  of  right 
chest.  Right  intercostal  spaces  oblit- 
erated. Under  right  clavicle  _  semi- 
globular  tumor,  tense  and  elastic.  14 
days  after  admission  enlarged  gland 
above  clavicle.  Admitted  August  28; 
died  October  5 


ChiUs,  fever,   facial  paralysis.  Pain 

right     chest.     Extensive     dulness 

from    below    upward    on    right    side. 

Bulging  of  intercostal  spaces;  cedcema 

of  right  hand;  enlarged  axillary  glands 

No  heredity.  Patient  was  received 
into  surgical  clinic  for  phlegmon  of 
penis  and  scrotum.  There  were  no 
lung  symptoms;  death  resulted  from 
the  surgical  affection 


No  heredity.  Emaciation,  vomit- 
ing, absence  of  free  HCl  in  stomach; 
pain  in  stomach  and  Liver;  dyspnoea; 
enlarged  liver  with  palpable  tumor 


After  "cold,"  cough,  pain  in  chest, 
loss  of  weight  for  4  months;  then 
oedoema  of  right  face,  neck,  chest, 
immensely  distended  veins.  Indurated 
glands  in  neck,  axilla  and  under  pec- 
torals. Tumor  as  large  as  orange 
protruded  from  chest,  eroding  3d  and 
4th  ribs.  On  physical  examination 
many  secondary  nodviles  in  both  lungs 

Cough,  difficult  breathing  for  2 
years.  Pain  in  right  chest,  intense 
dyspncEa,  hoarseness,  dysphagia.  Clini- 
cal diagnosis :  asthma  or  phthisis 


Always  in  good  health.  Month 
before  admission  dizziness  and  palpi- 
tation. Soon  after  pleuritic  effusion, 
dyspnoea.  Flatness  over  all  of  left 
chest;  dulness  over  right  phest.  Loss 
of  fremitus  on  left  side;  increased  on 
right.  Heart  dislocated  to  right. 
Congestion  of  lungs  is  diagnosed. 
No  puncture  is  made,  but  venesection. 
Death  in  asphyxia 


DOUBTFUL 


295 


Profuse; 
not  bloody 


AUTOPSY    NOTES 


life.  Both  pleural  layers  ad- 
herent to  diaphragm  and 
thorax.  Substance  of  right 
lung  studded  with  miliary 
granules  and  traversed  by 
fibrous  bands.  Left  lung 
also  involved  in  cancer. 
Posterior  mediastinum  filled 
with  morbid  deposit  and 
glands 

Right  lung  solidified, 
some  parts  being  "cartilag- 
inous and  greasy,"  others 
"like  liver."     Bronchial 
tubes  completely  occluded 

Tumor  size  of  a  small  fist 
in  left  lower  lobe  adherent  at 
its  free  surface  to  the  upper 
lobe.  On  section  seen  to  be 
composed  of  4  smaller  nod- 
ules 


Primary  nodule  in  lung 


None  made 


Almost  entire  right  lung 
converted  into  firm,  pulpy 
tumor  especially  at  root. 
Right  main  bronchus  ulcer- 
ated and  almost  obliterated 
by  tumor 


Serous  effusion  in  left 
pleura.    Both  lungs  studded 
with  nodules  size  of  a  cherry. 
No  tumor  anywhere  else 


METASTASES 


Axillary 
glands 


None 


Pericar- 
dium,  liver, 
both  pleurae, 
bronchial 
Ijonph 
nodes 


Bronchial 
glands 


None 


MICROSCOPE 


It  is  simply 
stated  that 
tumor  is 
"cancer" 


Microscopic 
examination 
seems  to  show 
fibromyoma. 
In  epicrisis 
author  calls 
the  tumor 
' '  fibrosar- 


Not  given 


No  details 


No  details 


Encepha- 
loid  cancer 


No    secondary 
symptoms,  no  metas- 
tases; nothing  speaks 
for  malignant  growth 


Probably  sarcoma 


Probably  primary 
carcinoma  of  right 
main  bronchus 


Probably  sarcoma 


296 


TABLE  III 


LUNG     IN- 
VOLVED 


CLINICAL   SYMPTOMS 


61 


62 


Lehlbach, 

Trans.   Med.   Soc.  of 

N.  J.,  1870,  p.  150 
Case    of    Primary    En- 

cephaloid    Cancer  of 

Right  Lung 


LiNDSET, 

Proceedings  of  Arkan- 
sas  Med.  Soc,  1899, 
p.  131 
An    Obscure    Case    of 
Pulmonary  Cyst 


M 


64 


R 


M 


30 


63 


64 


McAldowie, 

Lancet,  1876,  II,  570 
Cancer  of  lung  in  Child 

5*  Months  Old 


McPhedran, 

Canadian    Practi- 
tioner and  Review, 
Toronto,  XXV,  1900, 
p.  17 

Carcinoma  of  Lung  and 
Pleura  with  Occlusion 
of  Superior  Vena 
Cava 


M 


5^ 
mos. 


Both 


61 


Both 


65 


66 


Meissner, 

Schmidts  Jahrbiicher, 
1873,  Vol.  158,  p.  285 


Olmeh, 

Marseille  Med.,  1901, 
p.  279 


M 


16 


39 


Both 


Cough,  dulness  upper  portion  right 
chest  in  front,  bronchial  respiration. 
Pain,  increasing  emaciation  and 
debility;  night  sweats;  intermittent 
fever.  Left  lung  normal.  Later  hard 
painful  swelling  in  pectoral  muscle  over 
dull  area.     Duration  about  one  year 

In  prison  convicted  of  murder.  Nov. 
1898  oblong  fluctuating  tumor  over 
9th-llth  ribs  to  left  of  spine.  Flat- 
ness of  left  chest  anteriorly  and  pos- 
teriorly to  3d  rib;  also  absence  of 
breathing.  Several  probatory  punc- 
tures withdraw  nothing  but  blood. 
No  fluid  in  pleura.  Exploratory  in- 
cision made  in  tumor.  Arterial  blood 
flowed  from  incision  and  thoracic 
aneurysm  was  diagnosed.  Patient's 
appetite  good;  no  loss  of  flesh  or 
strength,  but  rather  gain.  History 
of  syphilis,  and  K  I  given.  Tumor 
continued  to  grow  and  an  enormous 
flow  of  blood  followed  the  introduc- 
tion of  the  smallest  needle.  Opera- 
tive interference  followed  by  enormous 
haemorrhage.     Death  March  1899 

No  heredity.  Normal  at  birth; 
other  children  healthy.  Failed  al- 
most at  once  after  birth.  Short  dry 
cough;  emaciation;  feeble  breathing; 
few  fine  rales.  No  dyspnoea.  Per- 
cussion clear  over  both  lungs 


No  heredity.  Chronic  bronchitis 
for  16  years.  About  year  before 
admission  pain  in  right  scapula,  arm, 
and  face.  Incipient  tuberculosis  of 
right  apex  suspected.  Severe  _  noc- 
turnal cough  and  sweats.  Pain  in 
right  chest,  weakness,  haemoptysis. 
Effusion  in  right  pleura;  heart  dis- 
placed. Several  aspirations  of  clear 
serum,  but  no  change  in  dulness. 
Increasing  dyspnoea  and  weakness; 
cyanosis  of  face,  arms,  chest,  and  hands; 
cyanosis  to  costal  margin,  but  not 
below.  No  respiratory  motion  right 
chest;  no  fremitus^  below  right  2d 
rib;  flatness  and  diminished  respira- 
tion.    Duration  about  2  years 

Pain  for  3  months  with  increasing 
debility,  cough,  swelling  of  limbs; 
intense  dyspnoea;  rapid  enlargement 
of  liver.     Duration  about  5  months 


Admitted  moribund;  died  within  a 
few  hours.  No  history.  Flatness  and 
amphoric     breathing     at     left     apex. 


DOUBTFUL 


297 


SPUTUM 

AUTOPSY    NOTES 

METASTASES 

MICBOSCOPE 

EEMARKS 

Streaked 

Almost  entire  right  lung 

No  details 

No  details 

Nothing  said  about 

with 

except   small   area   at   base 

other  organs 

blood. 

and  apex  converted  into  en- 

Later 

cephaloid    mass.     3d,    4th, 

purely 

and    5th   ribs    entirely    de- 

mucoid 

stroyed 

No  details 

Large  tumor  filling  whole 
left  chest  and  pushing  dia- 
phragm downward,  heart  to 
right   and   whole   left   lung 
above  3d   rib.     Erosion   of 
3    ribs    where    tumor    had 
pressed  out.    Cystic  portion 
of  tumor  had  been  cut  off  by 
Hgatures.    On  section  tumor 
showed  two  kinds  of  tissue: 
the  outer,  pinkish,   glisten- 
ing; inner,  medullary;  about 
1  of  bulk  of  tumor  compact 
fibrous    substance,    resem- 
bling decomposing  brain  tis- 
sue 

No  details 

No  details 

Probably  sarcoma 

No  details 

Both  lungs  studded  with 
hard   white   nodules;    hard 
mass  at   root  of  left   lung 
extending     through     entire 
thickness  of  lung.     Pulmon- 
ary  tissue   around   nodules 
quite   normal.     Pleurae 
thickened  and  adherent 

Bronchial 
glands 

None 

Bloody;   no 

Nodules  in  both  lungs, 

No  metas- 

Epithelial 

Probably    primary 

tubercle 

right  pleura,  and  diaphragm 

tases  in  ab- 

cells, prob- 

in pleura.     I.  A. 

bacilli 

dominal  or- 
gans 

ably  from  en- 
dothelium   of 
lymph  ves- 
sels;  colum- 
nar cells  and 
basement 
membrane, 
polymor- 
phous cells 

No  details 

Both  lungs  studded  with 
miliary    nodules.     In    right 
lung  tumor  size  of  cherry, 
soft,    yellowish   white  with 
hffimorrhagic  centre 

Liver, 
spleen,    kid- 
neys 

No  details 

No  details 

Cheesy  masses  in  right 

Lymph 

Dense,  fi- 

Author is  in  doubt 

lung.     Miliary  tubercles 

nodes  of  left 

brous,  very 

whether   it    is    carci- 

throughout both  lungs. 

bilus 

vascular 

noma  or  sarcoma  or 

298 


TABLE  III 


67 


68 


69 


60 


61 


Tuberculose  et  Cancer 
primitif  du  Poumon 


OSBOHNE,  O.  T. 

Yale  Med.  Jour.,  Vol 
IX,    1902,   p.   50 

A  Case  of  Primary  Car- 
cinoma of  the  Lung 


Peacock, 

London    Path.    Soc, 
XIV,  p.  40. 

Carcinoma  of  Left 
Lung  with  Secondary 
Deposits  in  Heart, 
Kidneys,  Suprarenals, 
etc. 


Peacock, 

Trans.  London  Path. 
Soc,  IX,  1859 


Pepphb, 

Trans.  College  of 
Physicians,  Penna. 
1850-53 


POKIER   ET   NeUVILLE, 

Jour,     des     Coimais- 
sances Med. prat.  T.  I. 
1833-34,  p.  104 
D6g6nerescence  squir- 
rheuse  de  la  totality 
du  Poumon  droit, 
Phthysie  consecutive. 


M 


M 


M 


68 


31 


58 


27 


24 


LUNG    IN- 
VOLVED 


Both 


R 


R 


clinical  symptoms 


Rales    throughout    both    lungs, 
fever 


No 


_  Always  healthy.  Recently  palpita- 
tion and  breathlessness.  2  months 
before  admission  some  trouble  with 
left  lung  had  been  found.  On  admis- 
sion absolute  flatness  of  entire  chest 
with  absence  of  voice  and  breathing 
and  loss  of  fremitus  except  at  very 
apex.  At  probatory  puncture  needle 
enters  hard  mass.  Clinical  diagnosis: 
tumor.  Dry  harassing  cough,  but 
never  pain.  Nodule  in  abdomen. 
Later  paralysis  of  left  recurrent. 
Dysphagia.  Asthmatic  attacks  with 
profuse  bronchial  secretion  from  right 
lung.  Centre  of  tumor  begins  to 
break  down.  Died  about  a  month 
after  first  visit 

Cough,  dulness  over  all  of  left 
chest.  Almost  entire  absence  of  breath- 
ing sounds;  feeble  vocal  vibration. 
Heart  displaced  to  right.  Swelling 
of  lower  costal  cartilages;  enlarge- 
ment submaxillary  glands.  Death 
from  exhaustion.  No  bronzing,  but 
dingy  complexion.  Duration  about 
8  months 


Disease  commenced  with  hgemoptysis. 
Later  larger  and  smaller  masses  were 
ejected  with  cough.  Dulness,  bron- 
chial respiration;  deficient  breathing; 
crepitation  over  varying  areas  in  both 
lungs.  Later  increasing  dyspnoea. 
Diarrhoea.  Pain  in  chest,  especially  left 
side.  General  anasarca  with  normal 
urine;  later  anasarca  disappeared  ex- 
cept in  face.    Duration  about  4  months 

Pain,  swelling  of  right  arm,  chest, 
and  mamma.  Feeble  pulse.  Flatness 
over  entire  right  chest;  bronchial 
breathing;  no  rales.  Right  chest 
distended;  dyspnoea,  slight  dysphagia. 
No  cough 


Grandfather  died  of  cancer.  Dry 
cough  for  several  years.  When 
lifting  a  heavy  weight  felt  sharp  pain 
in  right  side.  Some  weeks  later  tumor 
in  right  side,  where  pain  had  been. 
On  examination  dry  cough,  tumor  size 
of  filbert  adhering  to  6th  rib.  Dulness 
over  right  chest.     No  fever.     8  months 


DOUBTFUL 


299 


SPUTUM 

AUTOPSY   NOTES 

METASTASES 

MICROSCOPE 

REMARKS 

spleen,  and  liver.     Left  up- 

stroma en- 

a     combination 

of 

per   lobe   transformed   into 

closing    alve- 

both 

dense    grayish    tumor   con- 

oli filled  with 

taining  small  cavities 

partially  nec- 
rotic epithe- 
lial cells 

Occasion- 

Whole of  left  lung  shrunk- 

Both kid- 

No   micro- 

ally 

en  into  cancerous  mass  with 

neys   and 

scopic  exami- 

bloody, 

greatest  consolidation  at 

skin 

nation  made 

no  tuber- 

root.    Base  of  heart  at- 

cle bacilli. 

tached  to  tumor,  also  chest 

Numer- 

walls;  broken  down  in  cen- 

ous flat 

tre.     Right  lung  healthy 

epithelial 

cells 

thought 

to  be  al- 

veolar 

cells 

Bloody, 

Tumor  infiltration  of  al- 

Various 

No  details 

Probably  sarcoma 

large 

most  all  of  left  lung;  bron- 

lymph 

masses  of 

chiectatic  cavities 

nodes. 

pus 

heart,  peri- 
and   endo- 
cardium. 
Complete 
tumor  de- 
generation 
of  both  su- 
prarenals 

Bloody  and 

Tumor  masses  in  both 

None  in 

Both  tu- 

Probably sarcoma 

purulent. 

lungs  with  numerous  cavi- 

other organs 

mors  and  the 

masses 

ties  containing  pus  and  nec- 

coughed-up 

ejected 

rotic  material 

rnaterial  con- 
sist of  spindle 
and  round 
cells 

None 

Tumor    masses    through- 

Bronchial 

Not  stated 

Some  doubt 

out   right  lung.     In   medi- 

and mesen- 

whether   primary 

in 

astinum  a  large  tumor  sur- 

teric lymph 

lung 

rounding  aorta  and  com- 

nodes, head 

pressing    lower    cava,    pul- 

of pancreas. 

monary  artery,  trachea,  and 

and  ovaries 

oesophagus 

No  details 

Tumor  occupied  whole  of 
right  chest  and  part  of  left, 
adherent     to     pericardium, 
loft    costal    cartilages,    ster- 
num, right  ribs,  and  verte- 
bral column ;   around  6th  to 
8th    ribs    it     penetrates    to 

Probably 
in  abdomen. 
Statements 
not  very 
clear 

Not  given 

subcutis,   forming    there    a 

300 


TABLE  III 


LUNG    IN- 

NO. 

AUTHOR 

SEX 

AGE 

VOLVED 

CLINICAL    SYMPTOMS 

Mort   aprls   dix-neuf 

later  diagnosis  of  empyema  was  made, 

mois  de  Maladie;  N6- 

but  no  trace  of  liquid  was  found  on 

cropsie 

operation.     After  19  months  of  sick- 
ness:  extreme  emaciation,  chest  more 
distended  on  right  than  on  left,  hard 
nodulated  tumor  under  right  breast. 
Dulness  over  right  chest  with  absence 
of    respiration.     Tumor    in    abdomen 
attributed  to  liver.     CEdcema  of  lower 
limbs;    intense  dyspnoea 

62 

Powell, 

Middlesex   Hospital 
Reports,  1892.     Lon- 
don, 1894,  p.  87 

Malignant   Disease  In- 
vading  Right   Lung. 
Gastric  Ulcer 

M 

58 

R 

Sick  for  about  a  year  with  gastric 
symptoms.     Cough  for  about  3  years; 
lately   worse.  _   In   bed   for    19   weeks 
before  admission    with    dyspnoea   and 
wasting.     On    admission    oedoema    of 
right  arm,  dilated  veins  of  right  chest. 
Impaired    respiratory    motion.     Dul- 
ness and  flatness  over  most  of  right 
chest.     Feeble  or  bronchial  breathing. 
Heart  beyond  nipple  line.     No  change 
in    physical    symptoms    until    death. 
Duration  probably  several  years 

63 

Powell, 

London    Med.    Gaz., 
1850,XI,  pp.  1029,31 

F 

74 

R 

Severe  pain  in  right  chest.     Right 
lung  completely  dull;  feeble  breathing 
sounds.     Slight  cough 

64 

Pbevost, 

Compt.  rend.  Soc.  de 
Biol.,  1875-76,  II,  175 
-180 

M 

44 

R 

Cachexia.     Indefinite    dyspeptic 
symptoms.     Frequent     tappings     for 
hsemorrhagic  pleural  effusion.     Dysp- 
noea 

65 

Phtjdhomme, 

Union  Med.  du  Nord- 

Est,  Reims,   1903,   p. 

213 
Cancer  lobaire  primitif 

du  Poumon  Gauche 

M 

62 

L 

No  heredity.     For  5  months  rapid 
decline    of    strength.     Slight    attacks 
of   cough.     Flatness   on   left   anterior 
chest  from  top  to  below  left  mammilla; 
behind  about  2  fingers  below  spine  of 
scapula.     Over  all  this  area  absence 
of    voice    and    breathing.  _  No    rales. 
Dyspnoea  on  slight    exertion;     some 
hoarseness.     Later  oedcema  of  left  arm. 
Heart  displaced  to  right.     Increasing 
dyspnoea  and  emaciation.     CEdcema  of 
left  lung.     Aspiration  1000  c.c.  yellow 
serum.     CEdoema    improved,     but   no 
change  in  physical  signs.     Cough  with 
pain    in    shoulder.     Death    about    2 
mouths  after  admission 

66 

QUAIN, 

Trans.  London  Path. 
Soc,  1857,  VII 

F 

34 

L 

Symptoms  of  tuberculosis  —  cough, 
night  sweats,   cachexia,   dyspnoea, 
hoarseness,    dysphagia,    pain    in    left 
chest.     Dulness  over  left  apex,  dimin- 
ished breathing;  rales 

67 

Robertson, 

Glasgow  Med.  Jour., 

M 

37 

R 

No  heredity;    no  syphilis.     Cough, 
pain  across  chest;  cyanosis,  dyspnoea, 

DOUBTFUL 


301 


No  details 


large,  white,  nodulated  lar 
daceous  mass.  Tumor  had  3 
cavities  containing  serum 
and  pus.  At  upper  and  po& 
terior  part  of  tumor  a  thin 
layer  of  lung  tissue;  remain- 
der all  scirrhous.  Upper 
lobe  right  lung  compressed 
by  tumor.  Heart  displaced 
to  left.  Albuminous  mass 
in  abdomen 

It  is  simply  stated  malig- 
nant growth  invading  right 
lung;  old  gastric  ulcer.  No 
other  details  given 


Scant,  haem- 
optysis 


Yellow,  al- 
bumin- 
ous 


Scanty 
showed 
nothing 
charac- 
teristic 


Scant, 
mucoid. 
Hffimop- 
tysis 


Mucopuru- 
lent,   oc- 


AUTOPST    NOTES 


Slight  effusion  in  pleura 
Right  lung  almost  complete- 
ly transformed  into  solid 
cartilaginous  tumor 

Tumor  with  cavity  at 
base  of  right  lung 


Entire  upper  left  lobe  in 
vaded  by  cancerous  mass 
broken  down  and  forming 
cavities  containing  creamy 
matter 


Large  tumor  between 
apex  of  left  lung  and  arch  of 
aorta.  Compression  of 
oesophagus  and  left  bron 
chus.  Mass  between  tra- 
chea and  oesophagus  pressing 
on  recurrent  laryngeal.  Left 
lower  lobe  infiltrated  with 
soft  tumor 

Simply  stated  that   "tu- 
mor was  found  to  be  a  lym- 


MBTA8TA8E3 


No  details 


No  details 


Right  lung 
and  pleura 


Cancerous 
nodules    in 
mediasti- 
num ex- 
tending to 
pericardium 
compressing 
aorta  and 
pulmonary 
artery.     No 
other  metas 
tases 


Bronchial 
and  medias- 
tinal lymph 
nodes 


No  details 


MICROSCOPE 


No  details 


None  made 


No  details 


No  details 


No  details 


No  details 


Possibly   sarcoma 


302 


TABLE   III 


70 


71 


72 


73 


1889,  Vol.  XXXI,  p. 
454 
A  Case  of  Tumor  of  the 
Lung 


Rob, 

Lancet,  1866,  II,  723 


ROTTMANN, 

Diss.  Wiirzburg,  1898 
Uber     primares      Lun- 
gencarcinom 


Russell, 

London  Med.  Times 
and  Gaz.,  1864,  II,  p. 
278 


Rttssell, 

Lancet,   1869,  I,  814 


See  Germain, 

Revue  Med.,   1881, 

XXXI,  121-127 

L'Union  Med. 
Diagnostic  de  Cancer 

pulmonaire 


SiLVA, 

Gaz.  degli  Ospidali  e 
delle  cliniche  Milano, 
XXII,  1902,  Serie  II, 
p.  1236 
Sarcoma  primario  del 
Polmone 


M 


M 


M 


23 


47 


38 


30 


46 


52 


LTJNG    IN- 
VOLVED 


R 


CLINICAL   SYMPTOMS 


hoarseness.  Dulness  over  upper  por- 
tion right  lung;  increased  vocal  fremi- 
tus; prolonged  expiration;  all  kinds 
of  rales.  No  fever.  Enlarged  and 
tortuous  veins  of  abdomen  and  chest. 
Apex  beat  dislocated  to  left.  Heart 
sounds  heard  distinctly  over  dull 
area.  Rapid  increase  of  dulness  and 
some  bulging  of  right  chest  wall. 
(Edcema  of  hands;  sHght  exophthahnus 
of  right  eye.  Duration  about  4 
months 

Cough,  dyspnoea,  pain  in  chest. 
Flatness  and  harsh  respiration.  Right 
lung  normal.  Symptoms  of  peri- 
carditis and  pneumonia,  then  small- 
pox and  death 


Syphilis.  Complained  of  lungs  for 
2  years.  Emaciation  and  debility. 
Spontaneous  fracture  of  right  thigh. 
Flatness  at  right  base  posteriorly, 
slight  bulging  of  chest,  diminished 
voice  and   breathing.     Cough 

Extreme  dyspnoea.  Flatness  over 
left  chest.  Respiratory  immobUity; 
intercostal  spaces  retracted.  Explo- 
ratory puncture,  some  blood.  Lower 
lobe  cleared  up  before  death 

Distress  after  eating,  frequent  vomit- 
ing, cough,  dyspnoea,  palpitation.  Pain 
in  left  shoulder,  chest,  and  arm. 
Impaired  respiratory  motion.  Dul- 
ness at  apex  with  absent  breathing  and 
voice.     Effusion  in  left  chest 


Pain,  dyspnoea.  Flatness  and  ab- 
sence of  voice  and  breathing  over  left 
chest.  Small  hard  lymph  nodes 
above  clavicle 


No  heredity.  7  years  ago  acute  pul- 
monary disease  with  cough.  For  one 
month  dry  cough,  and  severe  pain 
radiating  to  both  lower  limbs  and  left 
shoulder;  also  behind  sternum.  No 
fever.  Obstinate  constipation;  ano- 
rexia. Impaired  expansion  of  left 
chest;  loss  of  voice  and  breathing. 
Complete  flatness.  Emphysema  of 
right  lung.  Two  punctures  withdraw 
small  amount  of  bloody  serum,  but 
needle  enters  into  hard  tumor  mass. 
Slight  fever  and  much  intestinal  dis- 
turbance. Death  after  3  months  in 
hospital 


DOUBTFUL 


303 


SPUTUM 

AUTOPSY    NOTES 

METASTASES 

MICROSCOPE 

REMARKS 

casion- 

phadenoma  probably  origi- 

ally 

nating  in  mediastinum, 

tinged 

some  portions  of  it  having 

with 

caseated  and  broken  down" 

blood 

One  hfiem- 

At  base  of  left  lung  hard 

Right  lung 

No  details 

Possibly   sarcoma 

optysis 

cartilaginous  tumor,  com- 
pressing bronchus  and 
oesophagus  and  extending  to 
left  auricle.     Bronchiectatic 
cavities  throughout  left  lung 

Abundant 

Large   tumor   in   right 

Bronchial 

Partly  car- 

lower lobe,  partially  necrotic 

lymph 

cinoma,  part- 

and  purulent.     Lower   and 

nodes    and 

ly  sarcoma 

middle  lobes  diffusely  infil- 

right femur. 

trated.     Left  lung  normal 

No  others 

No  details 

Hilus   of    left    lung    sur- 
rounded by  tumor  envelop- 
ing bronchus  and  large  ves- 
sels.    Infiltration   of  upper 
lobe 

Left  bron- 
chial lymph 
nodes  only 

No  details 

Bloody 

Cancerous  nodules  around 

Bronchial 

No  details 

root  involving  posterior  up- 

lymph 

per  left  lobe,  extending  into 

nodes 

left  auricle.     Tumor  prolif- 

erates along  bronchial  tract. 

Left  bronchus  and  pulmo- 

nary veins  compressed 

Pus   and 

No  autopsy 

Axillary 

No  details 

There  was  no  au- 

blood 

and   supra- 
clavicular 
lymph 
nodes 

topsy,  but  the  physi- 
cal signs  and  sputum 
as  well  as  absence  of 
fever    and   rapid    ag- 
gravation, all  point  to 
tumor  of  lung 

No  details 

Left  lung  shrunken  and 

Liver,  su- 

No  details 

Probably  carci- 

adherent, containing  tumor 

prarenals. 

noma 

size  of  melon,  hard  and  fi- 

ribs, verte- 

brous and  adherent  to  peri- 

brae 

cardium.    Pulmonary  artery 

compressed.     In  interior  of 

tumor    numerous    bronchi- 

ectatic   cavities    filled  with 

purulent     secretion.     Lung 

tissue    surrounding    tumor 

atelectatic  and  cedcematous 

304 


TABLE   ni 


NO. 

AUTHOR 

SEX 

AGE 

LTTNG    IN- 
VOLVED 

CLINICAL    SYMPTOMS 

74 

Sims, 

Medico-Chirurg. 
Trans.,   Vol.    XVIII, 
London,  1833,  p.  281 

On  Malignant  Tumors 
connected  with  the 
Heart  and  Lungs 

M 

43 

R 

For  about  a  year  before  admission 
various  haemoptyses,  sometimes  pro- 
fuse ;  dyspnoea  and  severe  oppression. 
Later  harassing  cough.  Dulness  on 
right  chest  anteriorly;  absent  breath- 
ing. Dilated  jugular  veins;  sweUing 
of  head  and  neck.  Diagnosis  made 
during  life 

75 

Log.  cit. 

M 

64 

L 

Hemiplegia  for  about  12  months. 
Cough  and  other  pulmonary  symptoms 
for  several  years.  Brain  sjrmptoms 
predominated  and  no  attention  was 
paid  to  lungs 

76 

Spabks, 

Lancet,  1871,  II,  13 
Primary  Cancer  of  the 

Lungs 

F 

22 

L 

Diagnosis  of  pleuro-pneumonia.  No 
other  clinical  data 

77 

Steell, 

Lancet,  1894, 1,  p.  388 
A  Case  of  Tumor  of  the 

Lung 

M 

49 

L 

No  previous  illness.  No  symptoms 
pointing  to  lungs.  Routine  examina- 
tion showed  dulness  over  whole  left 
chest  with  loss  of  fremitus  and  absence 
of  breathing  over  lower  part  chest. 
Slight  cough.  Later  high  fever  and 
pericardial  friction.  Clinical  diag- 
nosis: fibroid  phthisis 

78 

Stokes, 

New  Syd.  Soc.  Ed., 

1882,  p.  386 
Diseases  of  the  Chest 

M 

36 

R 

Some  pains  in  right  side;  cough, 
hoarseness,  dyspnoea;  cedoema  of  face 
and  neck.  Dulness  over  entire  right 
chest;  gradually  loss  of  voice  and 
breathing  sounds.  Heart  sounds 
heard  all  over  right  chest.  Later  en- 
larged liver  and  jaundice.  Tumors 
appear  on  forehead,  lower  jaw,  and 
lumbar  spine.  Diagnosis  of  tumor 
made  during  life 

79 

Log.  cit. 

M 

45 

L 

Pain  in  left  side,  dyspnoea,  dysphagia. 
Later  left  hemiplegia  and  epileptiform 
attacks.  Left  radial  smaller  than 
right.  Flatness  over  entire  upper 
left  chest;  feeble  breathing.  Dia- 
stolic pulsation  and  bellows  murmur 
in  upper  sternal  and  subclavicular 
regions;  nevertheless  tumor  and  not 
aneurysm  was  diagnosed 

80 

Stokes, 
Loc.  cit 

F 

34 

R 

After  a  cold,  cough  and  pain  in  right 
side.  Cachexia;  right  side  tender  to 
touch.  Tympanitic  percussion  note; 
cavernous  breathing;  tympanitic  note 
later  replaced  by  flatness.  Night 
sweats,  diarrhoea,  dyspnoea;  oedcemaof 
face  and  left  hand.  Duration  5  to 
6   months.      Diagnosis    made  during 

life 

DOUBTFUL 


305 


SPUTUM 

AUTOPSY    NOTES 

METASTASES 

MICROSCOPE 

BEMAEKS 

Mucoid, 

Solid    tumor    probably 

Bronchial 

No  details 

Possibly  carcinoma 

haemop- 

starting from  hilus  of  right 

lymph 

of  bronchial  origin 

tysis 

lung,  involving  greater  part 
of  right  chest  and  compress- 
ing   large   vessels,    trachea, 
and    right   main    bronchus. 
Bronchiectatic     cavities    in 
tumor.     Upper  cava  in- 
volved 

nodes  and 
heart 

No  details 

Upper  lobe  of  left  lung 
contains    tumor    size    of    a 
small   orange   of  medullary 
character.  Traces  of  chronic 
pneumonia  and   solid   gray 
hepatization,     also     a     few 
patches  resembling  gangrene 

None  men- 
tioned 

No  details 

No  details 

Large   nodulated    "en- 
cephaloid"  tumor  in  lower 
left    lobe    infiltrating    dia- 
phragm and  pleura.     Heart 
displaced  to  right 

Right  lung, 
both  pleurae 

No  details 

Scant, 

Effusion  in  left  chest.  Left 

No  details 

Insufficient; 

Possibly  carcinoma 

slightly 

lung  compressed ;  upper  lobe 

tumor  is 

bloody 

infiltrated  with  soft,  white 

called  lym- 

early  in 

new  growth.     Bronchus  of 

pho-sarcoma 

disease 

lower  lobe  almost   entirely 
obstructed  by  tumor.     Sup- 
purative   pneumonia   lower 
left   lobe 

Scant,  occa- 

Very large  tumor  in  place 

Mesenteric 

No  details 

Probably  sarcoma 

sionally 

of  right  lung  of  which  a  com- 

and   retro- 

bloody 

pressed  portion  is  found  over 
posterior  surface  of  tumor. 
Tumor  contains   cysts  and 
envelops  trachea,  large  ves- 
sels, and  pericardium.  Right 
main  bronchus  compressed 
and  obstructed 

peritoneal 
glands  com- 
pressing 
common 
bile  duct 

Bloody 

Large  tumor  from  root  to 

No  details 

No  details 

Possibly   bronchial 

apex  in  left  lung;    gangre- 

carcinoma 

nous  cavity  in  lower  lobe 

Copious, 

Entire  lung  converted  in- 

No details 

No  details 

Probably  bronchial 

frequent- 

to tumor   containing   bron- 

carcinoma 

ly  bloody 

chiectatic  cavities 

21 


306 


TABLE    III 


NO. 

AUTHOR 

SEX 

AGE 

LUNG    IN- 
VOLVED 

CLINICAL    SYMPTOMS 

81 

Loc.  CIT. 

M 

44 

R 

Cough,  dyspnoea,  pain.  Increasing 
dulness  over  right  lung.  Dilatation  of 
veins.  Feeble  respiration.  Increas- 
ing volume  of  chest.  CEdcsma  of  face 
and  chest.  A  month  later  some  im- 
provement; retraction  of  right  chest. 
Clinical  diagnosis:  empyema  and  ma- 
lignant tumor 

82 

Stone, 

Clinical   Cases    Med. 

&  Surg.,  New  York, 

1878.  p.  55 
Tumors  in  the  Lungs, 

etc. 

M 

4 

Both 

Always  thin  and  feeble.  Some  weeks 
before  death  difficult  breathing,  which 
became  "asthmatic."  Extreme  dysp- 
noea. Right  lung  solid  on  percussion ; 
bronchial  respiration.  Flatness  oyer 
left  lung;  mostly  bronchial  respira- 
tion; some  cough.  Clinical  diagnosis: 
thymus  asthma  or  pneumonia,  but  as 
there  was  no  fever  the  latter  was 
doubted 

83 

Strbhlin, 

Diss.  Miinchen,    1904 
Primares    Endotheliom 

eines  Hauptbronchus 

uad  der  Lunge 

M 

70 

R 

Practically  moribund  on  admission. 
Intense  dyspnoea,  cough.  Suffering 
more  or  less  for  a  long  time,  but  more 
in  the  last  2  months.  Owing  to  pa- 
tient's condition  examination  was  very 
imperfect.  Emphysema  of  both  lungs; 
loud  tracheal  rattle,  diffuse  rales  over 
both  lungs.  Clinical  diagnosis:  myo- 
degeneration of  heart,  bronchitis, 
arteriosclerosis,  emphysema 

84 

Suzanne, 

Journ.  de  Med.  de 
Bordeaux,      1883-4, 
XIII,  p.  573 

M 

35 

R 

Cachexia,  palpitation.  CEdcema  of 
right  face,  arm,  and  trunk.  Dilated 
veins.  Tumor  in  left  axilla  and  over 
clavicle.  Right  chest  flatness;  cavern- 
ous breathing;  imperfect  respiratory 
motion 

85 

TiNNISWOOD, 

London  &  Edinburgh 
Monthly  Journal  of 
Med.    Science,    1844, 
p.  550 
Lardaceous  Schirrhoma 
of  the  Lung  Involving 
the  First  Rib,  Clavi- 
cle, etc. 

M 

41 

R 

For  over  a  year  cough,  dyspnoea,  and 
occasional  hsemoptysis.  _Large_  hard 
tumor  arising  frorn  1st  right  rib  and 
clavicle.  Emaciation.  Dulness  over 
right  chest;  diminished  voice  and 
breathing.  Dilatation  of  veins  of  neck 
and  chest.  CEdoema  of  right  arm  with 
pain  and  numbness.  Fracture  of 
clavicle.  Duration  of  disease  about  a 
year  and  a  half 

86 

Trotter, 

British   Med.    Jour., 
1871,  II,  p.  583 

M 

30 

R 

Dulness  below  right  clavicle  with 
fine  rales.  Later  signs  of  cavity.  Still 
later  abdominal  pain,  fullness  and  tym- 
panites 

DOUBTFUL 


307 


BPUTUM 

AUTOPST   NOTES 

METASTASES 

MICROSCOPE 

EEMABKS 

Bloody  and 

Pus  in  right  pleura;  right 

No  details 

No  details 

"black 

lung  converted  into  large  tu- 

currant 

mor;  bronchiectases 

jelly" 

No  details 

Thjonua  pormal.    Tumors 
in   both  lungs  which   com- 
press lung  tissue ;   most  of 
the    tumor    subpleural,    al- 
though  some   imbedded   in 
lung.       Tumor      resembles 
Malaga  grapes  in  shape  and 
size;  white,  not  fatty 

No  details 

No  details 

Autopsy    incom- 
plete,   but    neverthe- 
less likely  that  tumor 
is  primary  in  lungs. 
Probably  sarcoma 

Bloody 

Large  quantity  of  turbid 

Both  kid- 

Fine fibrous 

May  be  classed  as 

serum  in  left  pleura;    right 

neys 

stroma     con- 

carcinoma   or    endo- 

pleura      obliterated.       Pri- 

taining nu- 

thelioma.      The 

mary  endothelioma  of  right 

merous 

branching   and   com- 

bronchus with  extension  in- 

branching 

municating    alveoli, 

to  lung.     Purulent  bronchi- 

and commu- 

probably lymphatics, 

tis.     Bronchiectatic    dilata- 

nicating alve- 

point to  endothelioma 

tion.     Purulent     degenera- 

oli filled  with 

tion  of  peribronchial  lymph 

small,  closely 

nodes      Pericesophageal  ab- 

packed cells 

scess.     Upper    and    middle 

like  endothe- 

right lobes  matted  together. 

lial  cells ;  here 

Bronchiectatic   cavity,    size 

and    there 

of  hen's  egg  with  numerous 

concentric 

small  gray  nodules  in  its  wall , 

layers  of  cells. 

communicates  with  dilated 

Much   necro- 

bronchus. Bronchi  filled  and 

sis 

obstructed  by  tumor  masses 

Some  haem- 

Fluid in  left  chest.    Heart 

Liver,  mes- 

No details 

optysis 

displaced     to     left.     Large 
vessels  compressed.     Tumor 
in  upper  cava.    Greater  part 
of    lung  converted  into  tu- 
mor connected  with   tumor 
in  mediastinum 

enteric 
glands 

Mucous, 

Right  upper  lobe  com- 

No details 

No  details 

Probably    primary 

often 

pletely  transformed  into  tu- 

sarcoma of  right  up- 

tinged 

mor  which  extends  into  mid- 

per lobe 

with 

dle  lobe.     Tumor  came  up 

blood 

from  lung  into  superior  tho- 
racic opening  and  involved 
clavicle  and  ribs.     Autopsy 
not  complete 

Haemopty- 

Right upper  lobe  almost 

Right  lung, 

No  details 

sis 

entirely    destroyed    by   soft 
tumor,  degenerated  and 
forming  a  cavity 

left  lung, 
kidneys, 
right  5th 
rib,  4th  left 
rib 

308 


TABLE   III 


87 


88 


89 


Von  Pflug,  H., 
..  Diss.  Munchen,  1904 
ijber   primare  Lungen- 
geschwiilste 


Van  Gieson, 

Medical  Record,  1879, 

XVI,  p.  495 
Cancer  of  Lung 


WaCHSMANN  &  POLLAK, 

New  York  Med.  Rec- 
ord, Nov.,  1904 
Three  Cases  of  Primary 
Malignant  Tumor  of 
the  Lung 


90  Log.  cit. 


M 


M 


liUNG    IN- 
VOLVED 


70 


30 


60 


91 


Wacqttez, 

Journ.  des  Sciences 
Med.  de  Lille,  Xlle 
Ann6e  (Tome  1, 1889) 
p.  393 

Cancer  primitif  du  Pou- 


M 


38 


46 


CLINICAL    SYMPTOMS 


For  several  years  cough;  later  pain 
in  left  chest,  increasing  cough  and  some 
fever.  Dulness  over  whole  of  left 
chest;  at  base  posteriorly  flatness. 
Over  dull  area  loud  bronchial  respira- 
tion, fine  mucous  rales.  Probatory 
puncture:  negative.  Tumor  suspect- 
ed. Slight  dysphagia.  Sudden  death 
through  profuse  haemoptysis 


No  heredity.  Severe  pain  in  left  chest; 
dry  cough.  Left  arm  cedcematous. 
Cyanosis;  dulness  below  left  clavicle. 
Left  chest  1 2  inches  larger  in  circumfer- 
ence. Absence  of  respiratory  sounds 
over  all  of  left  chest.  Exploratory 
puncture  negative.  Exophthalmus  left 
eye;  pupils  dilated.    Severe  dyspncea 

Commenced  with  pain  in  left  shoul- 
der and  cough;  hoarseness.  Flatness 
over  left  upper  lobe  and  at  base;  dimin- 
ished breathing  sounds.  Bulging  of 
left  thorax.  Clubbed  fingers.  Peri- 
osteal tumor  over  left  temporal  bone 


Cough,  pain  in  left  chest,  impaired 
respiratory  motion  and  flatness  from 
1st  rib  to  base.  No  respiratory  sounds 
in  left  axillary  line  or  in  back.  Paraly- 
sis of  left  vocal  cord 


No  heredity;  no  previous  illness. 
Sudden  expectoration  of  clotted  blood 
without  apparent  cause.  Recurrence 
shortly  with  considerable  haemoptysis. 
Some  sweating  and  fever.  Later  se- 
vere pain  along  spinal  column  and  at 
base  of  thorax ;  excessively  sensitive  to 
touch.  Cough  very  painful.  _  Increas- 
ing dyspnoea.  On  examination  right 
lung  normal.  Left  lung:  dulness  an- 
teriorly with  absence  of  breathing  and 
diminished  voice.  Puncture:  bloody 
effusion  containing  many  epithelial 
cells  with  granular  fatty  degeneration. 
No  relief  after  puncture.  Death  after 
about  6  days  in  hospital.  Duration 
from  first  haemorrhage  about  7  months 


DOUBTFUL 


309 


SPUTUM 

AUTOPSY    NOTES 

METASTASES 

MICHOSCOPE 

EEMAHKS 

At  first 

In  place  of  lymph  nodes 

Bronchial 

Fibrous 

Author     himself 

scant, 

at  bifurcation,  a  large  encap- 

lymph 

stroma  con- 

considers it  not  abso- 

later 

sulated   tumor,    perforating 

nodes 

taining  nu- 

lutely certain  whether 

more 

into  oesophagus  and  extend- 

merous   com- 

cells should  be 

abun- 

ing into  left  main  bronchus 

municating 

classed    as    epithelial 

dant. 

and  causing  extensive  ulcer- 

cavities lined 

or  endothelial  or  the 

Shortly 

ation.     Erosion    of    large 

or  completely 

tumor    as    endotheli- 

before 

branch  of  left  pulmonary  ar- 

filled with  flat 

oma  or  carcinoma 

death,  no 

tery.     Chronic  inflamma- 

endothelial- 

sputum. 

tion  of  left  lung;   numerous 

like  cells 

Occasion- 

bronchiectases 

tending  to 

ally  slight 

necrosis  and 

mixture 

often  ar- 

of blood. 

ranged    in 

No  tuber- 

successive 

cle  bacilli, 

layers 

no  tumor 

cells 

None 

Bloody    serum    in    left 
pleura.     Hard    white    neo- 
plasm involves  nearly  whole 
of  left  lung  which  is  adher- 
ent to  chest  wall  and  peri- 
cardium.    Tumor  in  apex  of 
right  lung 

_  Pericar- 
dium, right 
lung,  liver, 
sternocla- 
vicular ar- 
ticulation 

No  details 

Possibly   sarcoma 

No   blood, 

Incomplete  details 

Heart,  liver. 

No  details 

Probably  carci- 

no tuber- 

ribs, kid- 

noma 

cle  ba- 

neys, clavi- 

cilli. CeUs 

cles,  skull. 

which  re- 

suprarenals. 

semble 

mesenteric, 

cancer 

retroperi- 

cells 

toneal,  and 
regionary 
lymph  nodes 

Profuse, 

Entire  left  lung  taken  up 

Lymph 

No  details 

Probably  epitheli- 

greenish, 

by    soft    white    neoplasm; 

nodes,  liver. 

oma 

occasion- 

compression  of    oesophagus 

pericardium, 

ally 

and    trachea;    hsemorrhagic 

pleura 

bloody 

effusion    in    pericardium. 
Broncho-pneumonia    right 
upper  lobe 

Bloody, 

Bloody   effusion   left 

Right  lung 

No  details 

Probably  carci- 

frequent- 

pleura. Upper  left  lobe  solid 

and  left  su- 

noma 

ly  cur- 

grayish mass  of  encephaloid 

prarenal 

rant  jelly 

tumor;  softening  in  central 
portion.     Bronchi    permea- 
ble to   centre   of   neoplasm 
where  they  become  replaced 
with  neoplasm 

310 


TABLE   III 


92 


93 


94 


95 


96 


97 


98 


Waldenstrom,  J.  A. 

Deutsche  Klinik,  1874 

No.  22,  p.  169 
Cancer  Pulmonum 


Waters, 

British   Med. 
1886,  I,  335 


Jour., 


Weichselbattm, 
Virchows    Archiv., 
LXXXV,  1881,p.559 

Papillares  Adeno-sar- 
kom  der  Lunge 


White, 

Dublin  Quarterly 
Journ.    of   Medical 
Science,  1865, 
XXXIX,  219-222 


Williams, 

Lancet,  1878,  II,  732 
Cancer  of  Lung  and 

Pleuro-pneumonia 


Wilson, 

Edin.  Med.  Jour.,  1857 


Woodman,  Bathurst, 
Med.  Times  &  Gaz., 
London,  1876,  I,  p. 
411 

Case  of  Encephaloid 
Cancer   of    Bronchial 
Glands  and  Left  Lung 


M 


M 


31 


44 


67 


56 


40 


Not 
stated 


45 


lung  in- 
volved 

Not 
stated 


R 


R 


R 


CLINICAL   symptoms 


Anjemia,  dyspnoea ;  dulness  and  harsh 
respiration  over  left  base ;  sibilant  rales. 
No  other  signs  on  lungs  or  other  organs. 
CUnical  explanation  of  the  dyspnoea: 
emphysema,  although  no  signs  of  this. 
Rapid  increase  of  dyspnoea;  general 
bronchitis  with  abundant  secretion. 
Broncho-pneumonia ;  death 

Dyspnoea;  dulness  over  whole  right 
chest;  impaired  respiratory  motion, 
faint  breathing  and  fremitus.  22 
ounces  dark  fluid  removed  by  aspira- 
tion;   physical  signs  remain  unchanged 


Clinical    diagnosis:      bronchiectases 
and  effusion  into  right  pleura 


Pain;  slight  dulness  below  left 
clavicle;  in  some  parts  right  lung  total 
absence  of  breathing;  dulness  over  en- 
tire lower  posterior  portion  right  lung. 
Dysphagia,  hectic  fever.  Effusion  in 
right  chest 


Pain  in  left  chest,  increasing  dyspnoea 
and  emaciation ;  cough.  Dulness  at  base 
of  left  lung.  Diminished  respiration, 
but  increased  vocal  fremitus;  subse- 
quently complete  absence  of  breathing 
soimds.    Dysphagia.    Liver  enlarged 

Symptoms  of  pleurisy.  Dyspnoea, 
cachexia.     Duration  6  months 


For  10  months  bronchitis  and  loss  of 
wei'ght.  On  admission  pain  in  left 
side  and  left  arm.  Dulness  over  left 
chest,  bronchial  breathing,  absence  of 
fremitus.  Two  months  later  a  hard 
nodule  appeared  under  upper  border 
of  left  trapezius.  Two  months  later 
enlargement  of  left  axillary  glands  on 
mass  on  left  side  of  neck 


DOUBTFUL 


311 


SPUTUM 

AUTOPSY  NOTES 

METASTASES 

MICROSCOPE 

REMARKS 

No  details 

Simply  said  to  be  primary 
cancer  of  the  lung 

No  details 

No  details 

Scant,    rust 

Malignant  disease  of  right 

Pericar- 

No details 

Doubtful    whether 

colored 

pleura  involving  right  lung 
along  septa 

dium,  dia- 
phragm, 
large  and 
small  omen- 
tum 

primary  in  lung 

No  details 

Small  spherical  tumor 

No  details 

Multitudeof 

Author  calls  the  tu- 

near hilus  of  right  lower  lobe 

yiUi,  the  bod- 
ies of  which 
are  made  up 
of  round  and 
spindle- 
shaped     cells 
covered   with 
cylindrical 
epithelium. 
Glandular 
structures 
lined  with 
cylindrical, 
sometimes 
with  ciliated 
epithelium 
also  found 

mor  a  papillary  ade- 
no-sarcoma 

Bloody,  ex- 

At root  of  right  lung  a 

No  details 

No  details 

pectora- 

large tumor  extending  into 

tion  of 

lower  lobe;    posterior  medi- 

"fleshy- 

astinum   filled;    large  en- 

looking 

cephaloid    mass    projecting 

masses" 

into  pericardium.     (Esopha- 
gus compressed 

Rusty 

Large  nodular  tumor  at 
root  of  left  lung,  penetrating 
and  nearly  obliterating  left 
bronchus    and   invading 
lower  portion  of  lung 

None 

No  details 

Haemopty- 

Fluid in  left  pleura.     Sev- 

No details 

No  details 

sis 

eral  nodules  in  upper  part 
left   lung,    especially    along 
bronchi 

Elastic  fi- 

Tumor involving  upper  | 

Right 

No  details 

bres    and 

of  left  lung  and  connecting 

lung,  heart, 

pus  cells. 

with   mass   in    neck.     Infil- 

iver 

No  tumor 

tration  extended  to  mucous 

elements 

membrane  of  left  main  bron- 
chus almost  completely  ob- 
structing   it.      Bronchiec- 
tatic  cavities  base   of  left 
lung 

312 


TABLE  III 


NO. 

AUTHOB 

SEX 

AGE 

LUNG    IN- 
VOLVED 

CLINICAL   SYMPTOMS 

99 

Yeo,  J.  Burnet, 
British  Med.  Jour., 
March  13,  1874,  p. 
342 

A  Case  of  Mediastinal 
Cancerous    Tumor 
Leading  to  Occlusion 
of  the  Right  Bron- 
chus, etc. 

M 

53 

R 

Cancer  and  tuberculosis  in  family 
history.     Had  lues  20  years  ago.     Six 
months  previous  to   admission   bron- 
chitis, chills,  pain  in  right  side.     Pleu- 
ritic exudate  which  was  entirely  ab- 
sorbed within  a  few  weeks.     On  ad- 
mission cachexia,  heart  pushed  to  right. 
Dulness  all  over  right  chest  and  feeble 
breathing 

DOUBTFUL 


313 


AUTOPSY  NOTES 


METASTASES 


MICBOSCOPB 


No  details  Tiunor  size  of  an  orange 
in  anterior  and  posterior 
mediastinum,  hard,  whitish 
extending  into  right  bron- 
chus almost  entirely  occlud 
ing  it 


Nodules 
in  right  up- 
per lobe 


Medullary 
cancer    with 
much  con- 
nective tissue 
and  charac- 
teristic cells 
with  large 
nuclei 


Probably  primary 
in  right  bronchus,  and 
the  tumor  in  anterior 
and  posterior  medi- 
astinum a  secondary 
inflammation  of  the 
lymph  nodes.     I.  A. 


314 


TABLE   IV 


BOEHIS, 

Arbeiten  aus  dem  Path 
Anat.  Institut  zu  Tu- 
bingen (Baumgarten) 
..Vol.  VI,  Ht.  2,  p.  539 
(jber   primares    Cho- 
rionepitheliom    der 
Lunge 


Briese, 

Beitrage  zur   wisseu' 

schaft.  Med.  Festschr 

etc. 
Braunschweig,    1897, 

p.  191 
Ein  Fall  von  metastasi- 

renden    Lungenendo 

theliom 


Bbunet, 

Bull.  Soc.  d'anat.  et  de 

Physiol,   de 

Bordeaux,   Vol.   XII 

1891,  p.  115 
Cancer  du  Poumon 


Charteris,  M. 
Lancet,  1874, 1,  p.  126 

On  Intrathoracic   Can- 
cer 


M 


M 


M 


28 


40 


20 


29 


LUNG    IN- 
VOLVED 


E 


R 


R 


CLINICAL    SYMPTOMS 


Married  at  22;  4  children.  Last 
childbirth  14  months  before  admission 
to  the  hospital.  A  few  weeks  before 
admission  cough,  expectoration,  night 
sweats,  pain  in  right  chest.  On  ad- 
mission dulness  at  apex  of  right  lung; 
flatness  over  remainder  of  lung,  bron- 
chial breathing,  numerous  friction 
rales.  Left  lung  normal.  Later  signs 
of  effusion  in  right  pleura.  Tappings 
withdraw  clear  yellow  serum.  Later 
several  abundant  hsemoptyses.  Death 
2§  months  after  admission 

No  heredity.  Pleurisy  on  right  side 
18  years  ago.  Since  then  cough,  ex- 
pectoration occasionally  very  abund- 
ant; once  haemoptysis.  For  2  years, 
after  attack  of  influenza,  more  cough, 
pain  in  chest,  progressive  loss  of  weight. 
Later  severe  intercostal  neuralgia  on 
right  side.  Dulness  and  diminished 
respiration,  loss  of  fremitus  over  all  of 
left  upper  lobe.  A  few  weeks  before 
death  nodules  from  the  size  of  a  hazel 
nut  to  that  of  a  hen's  egg  in  skin  of 
abdomen  and  leg,  which  when  incised 
show  a  viscid  fluid.  Death  in  extreme 
marasmus 

Four  years  before  admission  ampu- 
tation of  right  leg  at  thigh  for  tumor. 
One  month  before  admission  violent 
chiUs,  harassing  dry  cough,  intense 
dyspnoea.  Right  chest  bulging.  Flat- 
ness from  angle  of  scapula  to  base;  in 
front  from  infraclavicular  fossa  to  base. 
Intercostal  muscles  do  not  contract. 
Respiration  feeble,  distant.  Marked 
segophony.  Nothing  on  left  chest. 
Puncture,  600  c.c.  bloody  serum;  flat- 
ness not  diminished.  Gradually  all 
symptoms  increase;  cedoema.  Several 
punctures  made  and  after  the  last  de- 
cided improvement,  dyspncEa  better, 
cough  not  so  harassing;  respiration 
on  right  chest  almost  normal;  some 
pleuritic  friction.  After  a  few  days 
return  of  all  symptoms;  intense  dysp- 
noea, sibilant  rales,  failing  appetite  and 
fever.  Severe  pain  in  back  of  chest. 
Repeated  punctures,  always  bloody 
serum.  Death  about  2  months  after 
admission 

Pleurisy  5  years  previously.  11 
weeks  before  admission  caught  cold, 
followed  by  anorexia,  cough,  night 
sweats;  hsemoptysis  3  days  before  ad- 
mission, when  became  hoarse  and  tu- 
mor appeared  on  right  side  of  neck. 
On  admission  dyspnoea,  pain  in  epigas- 
trium, and  vomiting.  Dulness  over 
lower  half  of  right  chest  in  front  and 


MISCELLANEOUS 


315 


SPUTUM 

AUTOPSY    NOTES 

METASTASES 

MICROSCOPE 

REMARKS 

Greenish, 

Bloody,  turbid  fluid  in 

Both  lungs. 

Typical 

Clinical     diagnosis 

mucoid, 

left   pleura.     Nearly   whole 

None  in 

chorion     epi- 

was uncertain  though 

no  tuber- 

of right  lung  occupied    by 

lymph 

thelioma 

inclined  to  tuberculo- 

cle bacilli. 

large  tumor  besides  a  num- 

nodes. 

sis.     At  the  autopsy 

Haem- 

ber of  smaller  nodules.    The 

Haemor- 

no  definite  diagnosis 

optysis 

large  tumor  contains  hsem- 

rhagic  focus 

could  be  made.     Mi- 

orrhagic and  necrotic  areas. 

in  right 

croscope    alone    gave 

Tumor  penetrates  into  up- 

broad    liga- 

the proper  diagnosis 

per   cava   and   extends  up- 

ment 

ward  into  vein 

Tenacious, 

Cavity  size  of  fist  in  lower 

Skin,  liver, 

Endothe- 

Author gives  many 

contains 

part  of  left  upper  lobe,  filled 

kidneys. 

lioma.     Mu- 

reasons in  detail  why 

elastic  fi- 

with cheesy  masses  and  hav- 

left psoas. 

coid  degener- 

he  has    classed   this 

bres.    No 

ing    hard,    irregularly    pro- 

lumbar, and 

ation  of  cells. 

tumor  as  epithelioma 

tubercle 

truding  waUs 

11th  and 

Metastases 

and  not  carcinoma 

bacilli. 

12th   tho- 

are all  cystic 

Haemop- 

racic verte- 

and    contain 

tysis 

brae 

viscid,     tena- 
cious,     clear 
mucus 

Abundant, 

Whole  of  right  lung  trans- 

Large sec- 

Not given 

Probably  sarcoma. 

green 

formed  into  an  encephaloid 

ondary     tu- 

Remarkable   for 

irregular  mass  without  any 

mor  in  liver 

length     of     time,     4 

trace  of  lung  tissue,  adher- 

years    between     pri- 

ent in  its   entire   extent  to 

mary  and    secondary 

chest  wall.     Left  lung  nor- 

growth,   and    for    its 

mal 

recurrence  as  a  mas- 
sive tumor  involving 
whole  of    right  lung 

Scant, 

Large  cancer  at  tracheal 

No  details 

Not  given 

Course    of    disease 

rusty, 

bifurcation    extending    into 

remarkably    rapid 

later  pu- 

right lung,  adherent  to  pos- 

rulent, 

terior   wall    of   pericardium 

abun- 

and extending  through  into 

dant. 

both  auricles.     Right  vagus 

often 

imbedded  in  tumor 

bloody 

316 


TABLE   IV 


CotrVELAIBB, 

Annales  de  gynec.   et 
d'obst.,   LX,    1903 
DegSnerescence    Ky- 
stique  congSnitale  du 
Poumon,  etc. 


De  Gueldre, 

Annal.  de  la  Soc.  de 

Med.  d'Anvers,  LXII, 

1900,  83-89 
Cancer  generalise  du 

deux  Poximons 


M 


M 


6  days 


39 


LUNG   IN- 
VOLVED 


R 


Both 


CLINICAL   SYMPTOMS 


behind.  Some  dulness  on  left  side 
anteriorly.  On  right  side  anteriorly 
below:  diminished  expiration,  distant 
bronchial  breathing.  Increasing  dysp- 
noea and  aphonia;  swelling  over  right 
vocal  cord.  Death  on  23d  day  after 
admission 

Parents  normal  health;  good  family 
history,  uneventful  normal  pregnancy, 
normal  birth.  After  birth,  child  cried, 
breathed,  and  behaved  like  normal 
child.  On  5th  day  respiration  became 
short  and  rapid;  cyanosis  set  in;  child 
refused  breast  and  6  days  after  birth 
died.  No  precise  diagnosis  was  pos- 
sible 


Always  in  robust  health.  Several 
months  before  admission  marked  ema- 
ciation. Cavity  at  right  apex;  slight 
temperature ;  intelligence  slightly 
clouded.  Tympanitic  note  right  apex 
below  clavicle;  diminished  respiration 
and  amphoric  breathing  corresponding 
to  tympanitic  note.  Tympanitic  note 
at  both  bases.     Short  cough.     Clinical 


MISCELLANEOUS 


317 


SPUTUM 

AUTOPSY  NOTES 

METASTASES 

MICEOSCOPE 

BEMABKB 

None 

Middle  lobe  of  right  lung 
connected  with  an  enormous 
cystic    mass    causing    com- 
pression and  atelectasis  of 
upper  and  lower  right  lobes. 
Hypertrophy  of  right  ven- 
tricle of  heart.     Cysts  irreg- 
ular in  dimension 

No  details 

Cyst-ade- 
nomatous 
structure. 
Cuboid  and 
cylindrical 
epithelium 
with  base- 
ment mem- 
brane with 
irregular 
nuclei  near 
base.     Where 
normal   lob- 
ules   of    pul- 
monary tis- 
sue exist  they 
are  complete- 
ly atelectatic. 
The  bron- 
chial    ramifi- 
cations are 
represented 
by     irregular 
canals  of 
varying  cali- 
bre and  ex- 
tremely 
simple  struc- 
ture   out    of 
which   de- 
velop the 
adenomatous 
tubules.    The 
only    sugges- 
tion of  intra- 
lobular bron- 
chial differen- 
tiation   are 
patches  of  _ 
cartilage    im- 
bedded in 
connective 
tissue  in   the 
vicinity  of 
the  pulmo- 
nary vessels 

Abundant, 

Retroperitoneal   tumor 

Mentioned 

No  details 

Author    goes    into 

mucopu- 

size   of   child's    head    from 

under 

details  as  to  how  all 

rulent 

lumbar  lymph  nodes.     Nut- 
meg  liver,    numerous   nod- 
ules, larger  and  smaller; 
nodules  of  spleen;  2  nodules 
replace  left    testicle.    Both 

autopsy 

the  symptoms  point- 
ing to  tumor  of  the 
lung  were  wanting  — 
the  slight  cough,   no 
characteristic  spu- 

lungs  completely  filled  with 

turn,  no  dyspnoea,  no 

nodules.     Diaphragm   per- 

pain,  no  dilatation  of 

318 


TABLE   IV 


DiONISI, 

Arch,  di  biol.,  Firenze 
LVII,  1903,  p.  716 
SuUe  degenerazione  po- 
licistica  dei  polmoni 


Ehlich, 

Primares  Carcinom 
an  der  Bifurcation 
der  Trachea 

Monatschr.  f.  Ohrenhlk., 
1896,  No.  3,  p.  121 
(Klinik  v.  Schrotter) 


Kraus,  Joseph, 
Diss.  Bonn,  1893 

Ein  Fall  von  ausgedehn- 
tern  links-seitigen 
Pleuratumor 


M 


M 


M 


19 


65 


39 


LUNG    IN- 
VOLVED 


Both 


CLINICAL    SYMPTOMS 


diagnosis:  tuberculosis.  Enormous 
liver  also  taken  as  phthisical  symptom. 
No  fever.  Emaciation  continues  not- 
withstanding improved  appetite.  Mili- 
ary tuberculosis  is  thought  of,  but  lack 
of  fever  speaks  against  it.  Two  days 
before  death  tumor  as  large  as  a  fist 
and  painless,  is  recognized  in  left  flank. 
Death  one  month  after  admission 

For  some  time  cough,  dyspnoea,  slight 
cyanosis,  occasional  night  sweats.  End 
of  December,  1902,  fever,  dyspnoea, 
pain  about  right  breast.  Dulness  be- 
low right  spine  of  scapula;  harsh 
breathing  and  crepitant  rales.  Tem- 
perature up  to  39.1.  This  state  con- 
tinued until  January  5  with  rapid  de- 
crease of  temperature  and  signs  of 
heart  failure.     Death 


No  heredity;  no  serious  illness.  For 
2  years  cough  and  hoarseness  at  times. 
General  health  good.  Later  slight 
dyspnoea  on  exertion,  dysphagia,  dul- 
ness at  right  apex.  Laryngoscope 
shows  tumor  obstructing  both  right  and 
left  bronchus.  Intense  dyspnoea;  pneu- 
monia of  left  lower  lobe.  Attempt  at 
suicide  by  stabbing  in  chest;    death 

No  heredity.  Three  years  previ- 
ous to  admission,  left  pleurisy;  well 
after  2  months.  Since  then  occasional 
pain  in  left  chest,  though  working. 
For  some  months  constant  pain  in  left 
lower  chest,  cough,  increasing  dysp- 
noea, trigeminal  neuralgia.  Dulness 
left  upper  lobe;  absence  of  fremitus 
and  breathing.  Some  areas  of  bron- 
chial breathing  posteriorly.  Heart 
displaced  towards  right;  loud  systolic 
murmur  at  base.  No  pulsation  in 
jugular  notch.  Left  jugular  more 
full  than  right.  Probatory  puncture 
yields  only  a  few  drops  of  bloody 
serum.  Increasing  pain  in  left  axilla. 
CEdcema  of  upper  left  arm.  Paralysis 
of  left  vocal  cord.  Percussion  of  chest 
becomes  very  painful.  Right  pupil 
larger   than   left.     Clinical    diagnosis: 


MISCELLANEOUS 


319 


Rusty 


Mucoid,  at 
times 
bloody. 
No  tuber- 
cle bacilli 
no  tumor 
elements 


Mucoid, 
more  or 
less  abun- 
dant, 
never 
bloody 


AUTOPSY    NOTES 


f orated  both  sides  by  tumor 
From  history  taken  only 
after  death  of  the  patient 
it  appears  that  primary  tu 
mor  of  the  testicle  was  oper- 
ated some  years  previous 


Fibrinous  pleurisy  on 
right  side ;  acute  bronchitis. 
Left  pleura  thickened.     On 
section  of  right  lung  a  sys 
tem  of  numerous  cavities  of 
varying  size  and  alveolar  as- 
pect decreasing  in  size  and 
number  from  above  down- 
ward.    In  lower   lobe  very 
firm  alveolar  appearance, 
resembling  thyroid  gland. 
In  apex  of  left  lung  similar 
system  of  cavities.    Genuine 
lung  tissue  was  firm  with 
increased  consistency  like 
brown  induration 


Scirrhus  at  trachea  at 
bifurcation     extending     di- 
rectly   into    both    bronchi. 
Cancerous       infiltration  of 
oesophagus 


Bulging  of  left  chest :_ 
stomach  enormously  dis- 
tended, reaching  almost  to 
symphysis.  Heart  beyond 
right  mammillary  line. 
Clear  serum  in  pericardium. 
Grayish  red  tumor  masses 
fill  whole  of  left  pleural  cav- 
ity. Right  lung  displaced 
downward.  Tumor  masses 
between  spine  and  pericar- 
dium. The  tumor  fluctu- 
ates at  apex ;  lower  portion 
grayish  atheromatous  mas- 
ses with  numerous  hairs, 
cartilage,  and  bone.  (Der- 
moid cyst  of  mediastinum) 


METASTASES 


No  details 


None. 
Not  even  in 
adjoining 
lymph 
nodes 


Right 
pleura 


MICKOSCOPE 


Areas  of 
emphysema- 
tous lung  tis- 
sue ;    also 
areas  where 
the   lung  tis- 
sue   is    re- 
placed   by 
tubular 
structure,  the 
tubules   lined 
with     epithe- 
lium    mostly 
in  single  lay- 
ers and  cylin- 
drical ;    other 
tubules     sug 
gest     acinous 
structure ; 
others     filled 
with  exudate 
and  leuco- 
cytes 

Not  given 


Grajdsh 
red  tumor  is 
spindle  cell 
sarcoma 


veins,  no  bloody  ef- 
fusion in  pleura,  no 
lymph  nodes 


According  to  the 
author  this  is  not  a 
true  neoplasm,  but 
a  congenital  cystic 
process  depending 
upon  the  arrest  or  dis- 
turbance of  the  proc- 
ess of  development 


320 


TABLE    IV 


10 


11 


12 


Klemm, 

..Diss.  Munchen,   1905 

tjber  ein  primares  En- 

dotheliom  der  Lunge 


Labb:6, 

Gaz.des  Mai.  infantile 

etc.,  et  d'obstet. 

Paris,  1909.     No,  15, 

p.  113 
Kyste  hydatique 

pulmonaire  chez   une 

fillette  de  8  ans. 

Vomique,  Guerison 


Las^qtje, 

Arch.  Gen.  de  Med., 
1874,_  Vol.  I,  p.  486 

Pleuresie    droite    deve- 
lopp6e  sous  I'influence 
d'un  Lymphosar- 
come  en  voie  de 
generalisation 


M 


M 


30 


49 


LUNG    IN- 
VOLVED 


Both 


Both 


CLINICAL    SYMPTOMS 


tumor  in  chest  probably  not  carcinoma 
on  account  of  scanty  and  not  bloody 
sputum.  Bulging  of  left  chest;  left 
jugular  vein  becomes  hard.  CEdcemaof 
left  leg.  Increasing  dyspnoea.  Much 
albumin  in  urine.  Admitted  Aug.  23, 
1892;   died  November  11 

Extreme  dyspnoea.  No  lesions  could 
be  detected  in  lungs  or  heart  to  ex- 
plain dyspnoea.  Repeated  examina- 
tions with  bronchoscope  negative. 
Patient  died  of  suffocation  on  day  of 
admission  to  hospital 


Cough  and  bronchitis  for  a  long 
time.  First  seen  February,  1907. 
Since  August,  1906,  intermittent 
cough  with  febrile  attacks  and  sweat- 
ing. Some  scant  hcemoptyses.  Dif- 
fuse bronchitis  and  gastro-intestinal 
symptoms.  Diagnosis  of  intestinal 
grippe  is  made.  Beginning  of  May, 
breath  becomes  foetid.  X-ray  shows 
shadow  of  upper  |  of  left  lung  with 
sharp  border.  Dulness  below  clavicle; 
bronchial  respiration;  mucous  rales; 
absence  of  fremitus.  Pleuro-pneumonia 
is  diagnosed  and  puncture  is  made 
posteriorly  (!),  but  only  a  few  drops 
of  clear  serum  withdrawn.  32  hours 
thereafter  violent  pain  in  left  chest;  no 
fever.  Suddenly  vomited  large  quan- 
tities of  pus,  white,  thick,  and  foetid, 
containing  particles  that  look  Uke 
membrane.  Some  purulent  and 
bloody  mucus  is  expectorated.  After 
this  gradual  diminution  of  aU  symp- 
toms. Physical  signs  in  left  chest 
gradually  disappear  and  improvement 
is  followed  step  by  step  by  radiograph. 
September,  1907,  the  healing  is  com- 
plete except  some  signs  of  cavity  below 
left  clavicle 

Six  weeks  before  admission  pain  in 
right  chest  with  slight  chill,  fever  and 
dyspnoea  gradually  increasing.  Dul- 
ness from  angle  of  scapula  downward. 
Bronchial  breathing  above,  dimin- 
ished breathing  over  middle  \  and 
absence  of  breathing  at  base.  Dul- 
js  from  mammilla  downward  an- 
teriorly, also  with  absence  of  breath- 
ing. Liver  enlarged.  Later  renewed 
chill  and  next  day  exudate  filled  entire 
right  chest.     Profuse  sweats,  anorexia. 


MISCELLANEOUS 


321 


AT7TOPST   NOTES 


METASTASES     MICROSCOPE 


Sanguinolent  serum  in 
both  pleurse.    Almost  entire 
left  lobe  consists  of  very  firm 
and  dense  tissue  containing 
no  air  except  a  thin  periph- 
eral layer.     Fibrous  prolif- 
eration  along   bronchi. 
Everywhere    conglomera- 
tions   of    miliary    nodules. 
Lower  lobe  of  right  lung  in 
same  condition  as  left.     Up- 
per   lobe    numerous,    often 
confluent  miliary  nodules 


Bronchial, 

tracheal, 
and  medias- 
tinal lymph 
nodes 


Yellowish,  purulent  fluid 
in  right  chest;  right  lung 
completely  filled  with  puru 
lent  serum.  Right  bron- 
chus compressed  by  en- 
larged bronchial  glands, 
hard,  yellow,  and  cheesy  on 
section.  Nodules  in  left 
lung.  Numerous  nodules  in 
liver  up  to  size  of  small 
apple.  In  both  lungs  along 
the  larger  and  smaller  bron- 


Gastro- 
hepatic 
lymph 
nodes;     nu- 
merous nod- 
ules in  duo- 
denum 


Firm,  fi- 
brous tissue 
mostly  in  a 
state  of  hya- 
line degenera- 
tion. Nod 
ules  consist  of 
very  small 
fusiform  cells 
surrounded 
by  giant  cells 
No  tubercle 
bacilli 

Examination 
of  vomitus: 
portion  of 
membrane, 
non-charac- 
teristic bac- 
teria and  one 
unmistakable 
hook 


Nodules 
composed  of 
leucocytes, 
well  devel- 
oped embryo 
nal  cells,  and 
less  numerous 
spindle  cells 


Probably  sarcoma 


Primary  focus  not 
to  be  determined; 
possibly  in  lung 


22 


322 


TABLE   IV 


13  Lesieue  et  Rome, 

Lvons  Med.,  CXIII, 
July,  1909,  p.  74 
Cancer  massif  du  Pou-: 
mon,  secondaire  a  un 
Cancer  latent  du  Hec 
turn 


M 


14 


15 


LShleix, 

Verhand.  der  Deutsch, 

Path.  Gesellschaft, 

1908,  p.  Ill 
Cystisch  papillarer 

Lungentumor 


Ogle,  Ctril, 

Trans.  London  Path. 
Soc.  Vol.  XL VIII., 
1897,  p.  37 


16  RrniscH  &  Sch??vahtz 
Mt.  Sinai  Hosp.  Re- 
ports, 1903,  p.  26 
Primary  Sarcoma  of  the 
Lung  and  Pleura 


M 


U 


54 


69 


28 


33 


Lns'G    IN- 
VOLVED 


CLINICAL    SYMPTOMS 


cfidoema'of  abdominal  waU,  some  ascites. 
Puncture  vdthdrew  bloody  serum  and 
patient  felt  better,  but  physical  signs 
remained  the  same.  Liver  becomes 
larger.  Increasing  dyspnoea;  icterus. 
Death  4  weeks  after  admission.  Du- 
ration about  2  months 

Cough  for  years;  for  IJ  years  loss 
of  flesh  and  strength.  3  months  before 
entering  hospital  ceases  work.  On  ex- 
amination nothing  found  except  dulness 
left  base,  diminished  breathing,  some 
mucous  rales.  Continued  loss  of  weight, 
but  nothing  found  to  explain  condition 
except  the  few  signs  on  lungs.  Noth- 
ing could  be  felt  in  rectum.  Died  4 
months  after  admission.  During  all 
this  time  the  only  lung  sjTnptoms 
were  pain  in  left  chest,  dyspnoea,  and 
persistent  cough.  Vocal  fremitus 
preserved.  X-raj'  showed  extensive 
shadow  at  left  base  and  immobility  of 
left  diaphragm 

Died  of  tubercular  pericarditis 


Cough  and  occasional  haemoptysis 
for  5  years  intermittently.  Physical 
signs  suggest  empyema ;  hectic  tj-pe  of 
fever.  Death  from  profuse  haemop- 
tysia 


Xo  heredity.  Sj-philis.  Pain,  loss 
of  weight,  hoarseness.  Bulging  of 
left  chest.  Dilated  veins  of  upper  ex- 
tremities and  chest.  Flatness  and 
absence  of  voice  and  breathing.  As- 
piration negative.  Enlargement  of 
IjTnph  nodes,  liver  and  spleen.  CEdcema 
of  face,  left  arm  and  chest.  Increas- 
ing dyspnoea,  fever  up  to  104,  emacia- 
tion 


MISCELLANEOUS 


323 


SPTTTtrU 

AUTOPSY    NOTES 

METASTASES 

MICROSCOPE 

REMAEKS 

chi     and     scattered     under 

pleura  similar  nodular  foci 

At  times 

Massive  tumor  occupying 

In  liver  and 

Tumor  of 

Only    example    of 

sanguin- 

nearly  all  of  left  lower  lobe, 

under  dia- 

lung  consists 

large  massive  second- 

olent,  no 

only  a  very  small   strip   of  phragm.  All 

of  typical  cy- 

ary lung  tumor.     Au- 

tubercle 

lung    tissue     persisting     at 

other  organs 

lindrical 

thor  justly  says  that 

bacilli. 

base.     Tumor  broken  down 

healthy 

celled    carci- 

if   autopsy    had    not 

Mostly 

in  places  gives  impression  of 

noma  exactly 

been   so    carefully 

muco- 

primary tumor  in  lung.     In 

hke  that  of 

done,  this  case  would 

purulent 

rectal  ampulla   6   cm  from 

recttoiQ 

undoubtedly    have 

and 

anus  a  carcinomatous  ulcer 

been    classified    as 

scant. 

evidently  primary 

primary  lung  tumor. 

Haemop- 

It is  also  remarkable 

tysis  at 

that  there  were  prac- 

various 

tically  no  symptoms 

times 

of    the    rectal    carci- 
noma 

No  details 

_  Besides  the  tubercular  le- 

No details 

PapUlary 

Origin   possibly 

sions  there  was  found  a  tu- 

and cystic 

from    bronchial    mu- 

mor the  size  of  an  apple  in 

adenoma 

cous  glands 

lower  lobe   containing   cav- 

ities   filled    with    mucus; 

strands  and  ramifying  tracts 

of    spongy    tissue    between 

them 

Profuse 

Cavity  in  lower  lobe  sur- 

No details 

The  tongue- 

Origin probably  in 

haemop- 

rounded mainly  by  lung  tis- 

like projec- 

mediastinum   com- 

tysis. 

sue  communicates  with  left 

tions  have 

pressing   bronchus. 

Offensive 

main  bronchus  —  evidently 

stratified  epi- 

causing   bronchiecta- 

sputum 

a    bronchiectatic    cavity  — 

thelium    cov- 

tic cavity,  and  pene- 

suggested 

offensive  dark  red  contents. 

ering  fatty 

trating   and   growing 

bronchi- 

Pear-shaped  flat  masses  of 

and  fibrous 

in  this 

ectatic 

tissue    roughly    resembling 

tissue  and 

dilata- 

skin and  covered  _with  hair 

having  many 

tion 

protrude   into   this    cavity. 
Several  stalks  are  joined  in- 
to one  mass  which  can  be 
traced  beyond  the  ca'V'ity  in- 
to the  mediastinum  to  right 
of  pericardial  sac.     Sac  con- 
tains sebaceous  matter, 
hairs  1 J  inches  long,  and  one 
large  tooth 

sebaceous 
glands 

No  details 

Entire  left  chest  and  medi- 

Retro- 

Simply 

astinum   filled  with   tumor. 

peritoneal 

stated    that 

Heart    dislocated    to   right. 

lymph 

tumor   is   en- 

Large abscess  in  tumor  con- 

nodes 

dothelioma 

taining  putrid  pus 

324 


TABLE    IV 


17 


18 


SOMMERS, 

N.  Y.  Med.  Record, 
LX,  1901,  p.  475 
Dermoid  Tumor  of  the 
Lung 


SORMANI, 

Gazz.  d.  Osp.,  Milano, 
1890,  XI,  p.  314-322 
Di  un  Caso  di  Cisti  Der- 
moids del  Polmone 
sinistro 


M 


27 


26 


LUNG    IN- 
VOLVED 


REMARKS 


Died  of  chronic  pulmonary  phthisis. 
Both  lungs  tubercular  and  cavernous 


No  heredity.  Was  first  child;  preg- 
nancy and  birth  normal.  As  baby 
during  first  4  months  very  susceptible 
to  cold  and  exposure  to  open  air. 
After  lengthy  nursing  had  to  be  held 
in  upright  position,  as  she  was  seized 
with  strong  attack  of  coughing  and 
dyspnoea.  Cough  increased  as  she 
grew  older;  also  dyspnoea;  cyanosis  of 
lips.  In  her  16th  year  hairs  were  no- 
ticed in  her  usually  mucoid  sputum; 
they  were  supposed  to  have  been  in 
food  eaten  and  no  further  attention 
was  paid  to  them.  Some  time  later  a 
whorl  of  black  hair  was  expectorated. 
Phthisical  habitus.  Harassing  cough 
and  dyspnoea  increased.  Last  two 
years  of  Uf e  in  bed ;  the  slightest  move- 
ment, even  turning,  caused  severe  pain 
in  chest  and  excessive  dyspnoea.  Could 
not  eat  for  dyspnoea.  Would  not  seek 
medical  aid,  saying  there  was  no  cure 
for  a  poor  consumptive.  Admitted  to 
hospital  July  17,  1887.  Exact  exami- 
nation could  not  be  made  on  account 
of  moribund  condition  of  the  patient. 
Death  several  hours  after  admission 


MISCELLANEOUS 


325 


No  details 


Mucoid, 
hairs 


AUTOPSY   NOTES 


Besides  the  tubercular 
condition  a  cystic  body  was 
found  at  apex  of  right  lung 
containing  large  masses  of 
hair  and  some  "dentoid 
bodies" 

Left  pleura  adherent.  On 
section  of  left  lung  yellowish 
gray  creamy  atheromatous 
material  of  nauseating  odor 
and  containing  small  brown 
hairs.  Nearly  the  entire 
upper  lobe  and  f  of  lower 
converted  into  a  large  pouch 
the  size  of  a  new-born  child's 
head,  containing  the  ather- 
omatous material.  The  wall 
of  the  cavity  is  firm  and 
hard  and  does  not  communi- 
cate with  a  bronchus.  There 
are  many  places  covered 
with  longer  or  shorter  brown 
hair.  In  some  places  it  re- 
sembles cutis  covered  with 
hair;  there  are  also  small 
spots  resembhng  cartilage. 
There  is  a  small  cyst  size  of 
a  nut  above  hUus,  also  a 
large  one  having  the  same 
structiu'e  and  characteris- 
tics except  that  the  hair  is 
black.  Right  lung  normal. 
Turbid  serum  in  right  pleura 
and  pericardium 


METASTASES 


No  details 


MICEOSCOPE 


No  details 


Wall   of  sac 
resembles 
cutis  in 
structure 
with  typical 
papillEe, 
hairs,  epi- 
thelium, 
sebaceous 
glands,  etc. 


PLATES 


Plate 


■  0^    *T-*':  ■ 


Plate 


f 


Plate  III 


Plate  IV 


Plate  V 


Plate  VI 


Plate  Vil 


Plate  VIII 


Plate  IX 


^S^ 


"'=^'  ''^ 


Plate  XI 


Plate  XII 


Plate  XII 


w 


Plate  XIV 


Plate  XV 


Plate  XVI 


»iaRBP.sfi»,(.      -77,'  .    -»■  ^ 


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